- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,282.84 / $7,340.00 / $13,413.92
| Facility | | $1,282.84 | $7,340.00 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.28 / $459.56 / $2,164.42
| Professional | | $248.28 | $459.56 | $2,164.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.32 / $997.32 / $1,462.33
| Professional | | $997.32 | $997.32 | $1,462.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.76 / $2,080.81 / $3,030.20
| Facility | | $371.76 | $2,080.81 | $3,030.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.28 / $2,005.50 / $2,967.69
| Professional | | $772.28 | $2,005.50 | $2,967.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.20 / $1,744.00 / $2,682.00
| Professional | | $1,285.20 | $1,744.00 | $2,682.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.76 / $2,080.81 / $3,030.20
| Facility | | $371.76 | $2,080.81 | $3,030.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.25 / $1,633.55 / $2,682.00
| Professional | | $641.25 | $1,633.55 | $2,682.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.85 / $1,764.86 / $2,924.65
| Professional | | $1,169.85 | $1,764.86 | $2,924.65 |