- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,884.03 / $2,884.03
| Facility | | $1,862.09 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,344.23 / $2,951.21
| Professional | | $1,122.02 | $2,344.23 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $3,801.89
| Professional | | $1,778.28 | $2,344.23 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $2,818.38 / $2,818.38
| Professional | | $302.00 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $2,290.87 / $18,197.01
| Facility | | $245.47 | $2,290.87 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,659.59 / $2,691.53
| Professional | | $1,122.02 | $1,659.59 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $1,288.25 / $2,290.87
| Facility | | $181.97 | $1,288.25 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $2,691.53
| Professional | | $1,096.48 | $1,659.59 | $2,691.53 |