- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,819.70 / $1,995.26
| Facility | | $870.96 | $1,819.70 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $1,949.84
| Professional | | $812.83 | $1,000.00 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,819.70
| Professional | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $3,981.07
| Facility | | $2,041.74 | $2,041.74 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,318.26 / $1,949.84
| Professional | | $870.96 | $1,318.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,235.94 / $7,244.36
| Facility | | $851.14 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,047.13 / $1,862.09
| Professional | | $851.14 | $1,047.13 | $1,862.09 |