- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,578.97 / $10,175.36 / $14,552.94
| Facility | | $3,578.97 | $10,175.36 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.54 / $341.27 / $1,352.19
| Professional | | $286.54 | $341.27 | $1,352.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.16 / $1,000.16 / $1,000.16
| Professional | | $1,000.16 | $1,000.16 | $1,000.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.41 / $1,352.19 / $1,933.63
| Facility | | $362.41 | $1,352.19 | $1,933.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.40 / $1,795.50 / $2,373.35
| Professional | | $691.40 | $1,795.50 | $2,373.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.75 / $1,239.75 / $1,843.60
| Professional | | $1,068.75 | $1,239.75 | $1,843.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.41 / $1,352.19 / $1,933.63
| Facility | | $362.41 | $1,352.19 | $1,933.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.15 / $1,246.50 / $1,859.82
| Professional | | $396.15 | $1,246.50 | $1,859.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.44 / $1,200.18 / $1,854.44
| Professional | | $723.44 | $1,200.18 | $1,854.44 |