- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,511.32 / $7,340.00 / $13,413.92
| Facility | | $1,511.32 | $7,340.00 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.19 / $1,773.93 / $2,563.25
| Professional | | $341.19 | $1,773.93 | $2,563.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.89 / $1,309.33 / $2,387.73
| Professional | | $883.89 | $1,309.33 | $2,387.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.43 / $1,773.93 / $3,588.55
| Facility | | $391.43 | $1,773.93 | $3,588.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.75 / $1,806.87 / $3,630.90
| Professional | | $1,002.75 | $1,806.87 | $3,630.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.00 / $2,260.13 / $3,190.00
| Professional | | $1,550.00 | $2,260.13 | $3,190.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $469.44 / $1,951.32 / $3,588.55
| Facility | | $469.44 | $1,951.32 | $3,588.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.75 / $1,990.80 / $3,118.84
| Professional | | $783.75 | $1,990.80 | $3,118.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.58 / $2,735.16 / $3,008.68
| Professional | | $1,367.58 | $2,735.16 | $3,008.68 |