- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $10,964.78 / $16,595.87
| Facility | | $1,122.02 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $416.87 / $1,778.28
| Professional | | $338.84 | $416.87 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $501.19 / $2,454.71
| Facility | | $371.54 | $501.19 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,071.52 / $2,570.40
| Professional | | $831.76 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $2,089.30
| Professional | | $1,513.56 | $1,513.56 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,778.28 / $2,511.89
| Facility | | $501.19 | $1,778.28 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $346.74 / $1,230.27
| Professional | | $60.26 | $346.74 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,000.00 / $2,344.23
| Professional | | $954.99 | $1,000.00 | $2,344.23 |