- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,741.00 / $10,175.36 / $13,413.92
| Facility | | $3,741.00 | $10,175.36 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.99 / $2,049.15 / $8,344.09
| Professional | | $158.99 | $2,049.15 | $8,344.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.53 / $617.53 / $5,543.03
| Professional | | $617.53 | $617.53 | $5,543.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.83 / $1,436.51 / $11,681.73
| Facility | | $220.83 | $1,436.51 | $11,681.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.37 / $1,447.42 / $9,939.29
| Professional | | $512.37 | $1,447.42 | $9,939.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.10 / $1,154.25 / $10,395.37
| Professional | | $710.10 | $1,154.25 | $10,395.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.83 / $1,436.51 / $11,681.73
| Facility | | $220.83 | $1,436.51 | $11,681.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.50 / $1,609.71 / $13,513.50
| Professional | | $657.50 | $1,609.71 | $13,513.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,186.79 / $6,651.63 / $11,284.08
| Professional | | $3,186.79 | $6,651.63 | $11,284.08 |