- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,259.71 / $7,340.00 / $13,413.92
| Facility | | $1,259.71 | $7,340.00 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.52 / $1,582.56 / $2,136.52
| Professional | | $298.52 | $1,582.56 | $2,136.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.74 / $1,128.24 / $1,950.41
| Professional | | $811.74 | $1,128.24 | $1,950.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $377.69 / $1,582.56 / $2,991.13
| Facility | | $377.69 | $1,582.56 | $2,991.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.60 / $1,349.82 / $2,712.45
| Professional | | $821.60 | $1,349.82 | $2,712.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.00 / $1,835.40 / $2,714.00
| Professional | | $1,270.00 | $1,835.40 | $2,714.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $417.03 / $1,740.82 / $2,991.13
| Facility | | $417.03 | $1,740.82 | $2,991.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.81 / $1,787.10 / $2,694.20
| Professional | | $664.81 | $1,787.10 | $2,694.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,206.44 / $2,111.27 / $2,654.17
| Professional | | $1,206.44 | $2,111.27 | $2,654.17 |