- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,818.38 / $12,882.50
| Facility | | $2,691.53 | $2,818.38 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,737.80 / $2,818.38
| Professional | | $1,148.15 | $1,737.80 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,677.35 / $5,011.87
| Facility | | $2,089.30 | $4,677.35 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,884.03 / $4,570.88
| Professional | | $2,238.72 | $2,884.03 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $11,481.54 / $26,302.68
| Facility | | $134.90 | $11,481.54 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $2,187.76
| Professional | | $1,698.24 | $2,041.74 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,137.96 / $4,365.16
| Facility | | $1,000.00 | $2,137.96 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,288.25 / $2,238.72
| Professional | | $851.14 | $1,288.25 | $2,238.72 |