- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,844.10 / $10,175.36 / $13,413.92
| Facility | | $1,844.10 | $10,175.36 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.07 / $2,542.14 / $3,127.67
| Professional | | $515.07 | $2,542.14 | $3,127.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.42 / $1,561.71 / $3,006.43
| Professional | | $1,262.42 | $1,561.71 | $3,006.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.07 / $2,542.14 / $4,378.74
| Facility | | $515.07 | $2,542.14 | $4,378.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.18 / $2,176.59 / $4,373.85
| Professional | | $1,453.18 | $2,176.59 | $4,373.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.30 / $2,915.50 / $3,646.00
| Professional | | $1,972.30 | $2,915.50 | $3,646.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $595.37 / $2,658.52 / $4,378.74
| Facility | | $595.37 | $2,658.52 | $4,378.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.92 / $2,689.50 / $3,569.55
| Professional | | $1,035.92 | $2,689.50 | $3,569.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.10 / $2,308.44 / $3,366.40
| Professional | | $1,413.10 | $2,308.44 | $3,366.40 |