- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,337.44 / $10,175.36 / $13,413.92
| Facility | | $3,337.44 | $10,175.36 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.61 / $1,101.63 / $5,278.18
| Professional | | $231.61 | $1,101.63 | $5,278.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.77 / $730.77 / $4,022.17
| Professional | | $730.77 | $730.77 | $4,022.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $264.50 / $1,379.29 / $7,389.45
| Facility | | $264.50 | $1,379.29 | $7,389.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $605.52 / $1,728.68 / $7,601.00
| Professional | | $605.52 | $1,728.68 | $7,601.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.30 / $1,460.65 / $7,445.88
| Professional | | $834.30 | $1,460.65 | $7,445.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $264.50 / $1,379.29 / $7,389.45
| Facility | | $264.50 | $1,379.29 | $7,389.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.32 / $1,566.04 / $7,445.88
| Professional | | $457.32 | $1,566.04 | $7,445.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,986.10 / $4,826.60 / $6,868.03
| Professional | | $2,986.10 | $4,826.60 | $6,868.03 |