- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.68 / $6,541.00 / $13,413.92
| Facility | | $1,230.68 | $6,541.00 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.97 / $1,230.68 / $2,087.29
| Professional | | $327.97 | $1,230.68 | $2,087.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.82 / $1,262.59 / $1,908.71
| Professional | | $955.82 | $1,262.59 | $1,908.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $383.28 / $1,916.51 / $2,922.21
| Facility | | $383.28 | $1,916.51 | $2,922.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.55 / $1,321.68 / $2,655.90
| Professional | | $1,003.55 | $1,321.68 | $2,655.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.80 / $2,080.75 / $2,488.54
| Professional | | $1,463.80 | $2,080.75 | $2,488.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $406.44 / $1,916.51 / $2,922.21
| Facility | | $406.44 | $1,916.51 | $2,922.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.88 / $1,996.50 / $2,701.60
| Professional | | $831.88 | $1,996.50 | $2,701.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $557.88 / $1,652.86 / $2,410.36
| Professional | | $557.88 | $1,652.86 | $2,410.36 |