- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,079.41 / $10,175.36 / $13,413.92
| Facility | | $1,079.41 | $10,175.36 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.22 / $998.18 / $1,830.71
| Professional | | $221.22 | $998.18 | $1,830.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.00 / $940.61 / $1,678.97
| Professional | | $613.00 | $940.61 | $1,678.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.67 / $1,229.39 / $2,562.98
| Facility | | $288.67 | $1,229.39 | $2,562.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.00 / $1,128.57 / $2,267.85
| Professional | | $617.00 | $1,128.57 | $2,267.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.75 / $1,453.75 / $2,286.00
| Professional | | $953.75 | $1,453.75 | $2,286.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.23 / $1,352.33 / $2,562.98
| Facility | | $315.23 | $1,352.33 | $2,562.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.71 / $1,392.00 / $2,234.69
| Professional | | $560.71 | $1,392.00 | $2,234.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.64 / $2,005.28 / $2,205.81
| Professional | | $1,002.64 | $2,005.28 | $2,205.81 |