- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $6,606.93 / $16,595.87
| Facility | | $1,096.48 | $6,606.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $446.68 / $1,096.48
| Professional | | $331.13 | $446.68 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,230.27 / $1,513.56
| Professional | | $912.01 | $1,230.27 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $630.96 / $2,454.71
| Facility | | $302.00 | $630.96 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,023.29 / $1,819.70
| Professional | | $776.25 | $1,023.29 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,445.44 / $2,137.96
| Professional | | $1,174.90 | $1,445.44 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $616.60 / $1,905.46
| Facility | | $331.13 | $616.60 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $501.19 / $1,230.27
| Professional | | $60.26 | $501.19 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,000.00 / $2,454.71
| Professional | | $389.05 | $1,000.00 | $2,454.71 |