- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,579.22 / $6,541.00 / $13,413.92
| Facility | | $1,579.22 | $6,541.00 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.38 / $2,460.27 / $2,678.41
| Professional | | $475.38 | $2,460.27 | $2,678.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.60 / $1,624.73 / $2,443.35
| Professional | | $1,227.60 | $1,624.73 | $2,443.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.28 / $2,460.27 / $3,749.77
| Facility | | $520.28 | $2,460.27 | $3,749.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.78 / $1,693.35 / $3,402.75
| Professional | | $1,285.78 | $1,693.35 | $3,402.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.20 / $2,667.00 / $3,176.80
| Professional | | $1,877.20 | $2,667.00 | $3,176.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.28 / $2,460.27 / $3,749.77
| Facility | | $520.28 | $2,460.27 | $3,749.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.63 / $2,501.94 / $3,258.45
| Professional | | $1,065.63 | $2,501.94 | $3,258.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.72 / $2,465.26 / $3,099.18
| Professional | | $1,408.72 | $2,465.26 | $3,099.18 |