- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.26 / $6,825.52 / $13,413.92
| Facility | | $1,300.26 | $6,825.52 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.30 / $461.37 / $2,205.27
| Professional | | $301.30 | $461.37 | $2,205.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.02 / $1,076.02 / $1,440.17
| Professional | | $1,076.02 | $1,076.02 | $1,440.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $401.67 / $2,205.27 / $3,087.38
| Facility | | $401.67 | $2,205.27 | $3,087.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.08 / $2,150.40 / $3,020.22
| Professional | | $828.08 | $2,150.40 | $3,020.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,371.60 / $1,900.00 / $2,535.83
| Professional | | $1,371.60 | $1,900.00 | $2,535.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $401.67 / $2,205.27 / $3,087.38
| Facility | | $401.67 | $2,205.27 | $3,087.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.89 / $1,706.40 / $2,535.83
| Professional | | $669.89 | $1,706.40 | $2,535.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.35 / $1,738.12 / $2,537.73
| Professional | | $1,103.35 | $1,738.12 | $2,537.73 |