- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $942.91 / $7,460.97 / $7,460.97
| Facility | | $942.91 | $7,460.97 | $7,460.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.37 / $942.91 / $3,318.81
| Professional | | $830.37 | $942.91 | $3,318.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,831.06 / $2,028.16 / $2,378.13
| Professional | | $1,831.06 | $2,028.16 | $2,378.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.50 / $1,858.21 / $2,822.85
| Professional | | $1,008.50 | $1,858.21 | $2,822.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $942.91 / $1,306.58 / $2,787.39
| Facility | | $942.91 | $1,306.58 | $2,787.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.26 / $1,609.27 / $9,862.15
| Professional | | $860.26 | $1,609.27 | $9,862.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,790.00 / $2,790.00 / $2,790.00
| Facility | | $2,790.00 | $2,790.00 | $2,790.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.06 / $1,714.04 / $2,192.76
| Professional | | $871.06 | $1,714.04 | $2,192.76 |