- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,299.23 / $7,340.00 / $13,413.92
| Facility | | $1,299.23 | $7,340.00 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.55 / $467.13 / $2,375.23
| Professional | | $321.55 | $467.13 | $2,375.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.62 / $644.98 / $1,434.70
| Professional | | $357.62 | $644.98 | $1,434.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $401.42 / $1,730.17 / $3,325.34
| Facility | | $401.42 | $1,730.17 | $3,325.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.05 / $1,494.63 / $3,006.96
| Professional | | $863.05 | $1,494.63 | $3,006.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.18 / $1,793.75 / $2,797.20
| Professional | | $1,010.18 | $1,793.75 | $2,797.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.48 / $1,730.17 / $3,325.34
| Facility | | $373.48 | $1,730.17 | $3,325.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.25 / $1,431.00 / $2,572.00
| Professional | | $513.25 | $1,431.00 | $2,572.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.34 / $1,147.76 / $3,165.91
| Professional | | $1,029.34 | $1,147.76 | $3,165.91 |