- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,337.42 / $7,830.00 / $13,413.92
| Facility | | $1,337.42 | $7,830.00 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.32 / $556.54 / $2,268.31
| Professional | | $276.32 | $556.54 | $2,268.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.42 / $1,148.82 / $2,119.37
| Professional | | $740.42 | $1,148.82 | $2,119.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $392.25 / $1,480.42 / $3,175.63
| Facility | | $392.25 | $1,480.42 | $3,175.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.53 / $1,409.97 / $2,833.35
| Professional | | $758.53 | $1,409.97 | $2,833.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.50 / $1,778.00 / $2,593.61
| Professional | | $1,172.50 | $1,778.00 | $2,593.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $392.25 / $1,628.46 / $3,175.63
| Facility | | $392.25 | $1,628.46 | $3,175.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $666.75 / $1,722.18 / $2,583.00
| Professional | | $666.75 | $1,722.18 | $2,583.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.56 / $2,060.73 / $2,590.63
| Professional | | $1,177.56 | $2,060.73 | $2,590.63 |