- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.42 / $10,175.36 / $13,413.92
| Facility | | $1,204.42 | $10,175.36 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.08 / $441.50 / $2,042.73
| Professional | | $261.08 | $441.50 | $2,042.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.53 / $1,054.32 / $1,845.32
| Professional | | $741.53 | $1,054.32 | $1,845.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $341.64 / $1,472.99 / $2,859.82
| Facility | | $341.64 | $1,472.99 | $2,859.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.80 / $1,242.11 / $2,496.00
| Professional | | $727.80 | $1,242.11 | $2,496.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.00 / $1,647.00 / $2,435.55
| Professional | | $1,125.00 | $1,647.00 | $2,435.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $377.16 / $1,620.29 / $2,859.82
| Facility | | $377.16 | $1,620.29 | $2,859.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.82 / $1,603.60 / $2,435.55
| Professional | | $622.82 | $1,603.60 | $2,435.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.85 / $1,962.45 / $2,467.08
| Professional | | $1,119.85 | $1,962.45 | $2,467.08 |