- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,227.17 / $10,175.36 / $13,413.92
| Facility | | $2,227.17 | $10,175.36 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.84 / $1,861.00 / $4,277.72
| Professional | | $369.84 | $1,861.00 | $4,277.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.88 / $1,127.88 / $2,672.21
| Professional | | $1,127.88 | $1,127.88 | $2,672.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $409.42 / $2,605.40 / $5,988.81
| Facility | | $409.42 | $2,605.40 | $5,988.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.26 / $2,269.73 / $5,094.54
| Professional | | $826.26 | $2,269.73 | $5,094.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.30 / $2,281.50 / $4,813.85
| Professional | | $1,347.30 | $2,281.50 | $4,813.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $409.42 / $2,605.40 / $5,988.81
| Facility | | $409.42 | $2,605.40 | $5,988.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.88 / $2,281.50 / $5,751.35
| Professional | | $1,127.88 | $2,281.50 | $5,751.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.76 / $3,206.64 / $4,937.64
| Professional | | $2,137.76 | $3,206.64 | $4,937.64 |