- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.45 / $7,340.00 / $13,413.92
| Facility | | $1,460.45 | $7,340.00 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.18 / $563.41 / $2,476.98
| Professional | | $307.18 | $563.41 | $2,476.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.35 / $1,261.59 / $2,321.69
| Professional | | $798.35 | $1,261.59 | $2,321.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.33 / $1,592.94 / $3,467.77
| Facility | | $325.33 | $1,592.94 | $3,467.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.80 / $1,541.97 / $3,098.55
| Professional | | $820.80 | $1,541.97 | $3,098.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.75 / $1,902.00 / $2,836.37
| Professional | | $1,268.75 | $1,902.00 | $2,836.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $423.92 / $1,752.23 / $3,467.77
| Facility | | $423.92 | $1,752.23 | $3,467.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.25 / $1,854.45 / $2,833.25
| Professional | | $713.25 | $1,854.45 | $2,833.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.98 / $2,255.71 / $2,835.76
| Professional | | $1,288.98 | $2,255.71 | $2,835.76 |