- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,089.30 / $5,011.87
| Facility | | $1,071.52 | $2,089.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,000.00 / $13,489.63
| Professional | | $549.54 | $1,000.00 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,022.64 / $14,454.40
| Facility | | $7,413.10 | $12,022.64 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,412.54 / $2,041.74
| Professional | | $812.83 | $1,412.54 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $1,288.25 / $2,041.74
| Facility | | $199.53 | $1,288.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $1,000.00 / $1,659.59
| Professional | | $407.38 | $1,000.00 | $1,659.59 |