- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,288.62 / $10,175.36 / $13,413.92
| Facility | | $3,288.62 | $10,175.36 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.50 / $1,967.15 / $6,316.47
| Professional | | $327.50 | $1,967.15 | $6,316.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.61 / $1,265.61 / $3,923.55
| Professional | | $1,265.61 | $1,265.61 | $3,923.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.21 / $2,940.87 / $8,843.06
| Facility | | $461.21 | $2,940.87 | $8,843.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.80 / $2,860.25 / $7,427.70
| Professional | | $1,120.80 | $2,860.25 | $7,427.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.45 / $2,461.92 / $6,869.25
| Professional | | $1,548.45 | $2,461.92 | $6,869.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.21 / $2,940.87 / $8,843.06
| Facility | | $461.21 | $2,940.87 | $8,843.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.61 / $2,461.92 / $8,284.45
| Professional | | $1,265.61 | $2,461.92 | $8,284.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,449.00 / $3,138.84 / $7,150.38
| Professional | | $2,449.00 | $3,138.84 | $7,150.38 |