- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,387.70 / $10,175.36 / $13,413.92
| Facility | | $1,387.70 | $10,175.36 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.18 / $1,568.59 / $2,353.60
| Professional | | $302.18 | $1,568.59 | $2,353.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $778.92 / $1,207.33 / $2,217.98
| Professional | | $778.92 | $1,207.33 | $2,217.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $312.70 / $1,568.59 / $3,295.04
| Facility | | $312.70 | $1,568.59 | $3,295.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.98 / $1,492.47 / $2,999.10
| Professional | | $819.98 | $1,492.47 | $2,999.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.50 / $1,922.50 / $2,895.75
| Professional | | $1,267.50 | $1,922.50 | $2,895.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $423.01 / $1,725.45 / $3,295.04
| Facility | | $423.01 | $1,725.45 | $3,295.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.63 / $1,764.00 / $2,895.75
| Professional | | $700.63 | $1,764.00 | $2,895.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,273.38 / $2,228.42 / $2,801.44
| Professional | | $1,273.38 | $2,228.42 | $2,801.44 |