- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,570.40 / $3,162.28
| Professional | | $1,862.09 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,691.53 / $3,630.78
| Professional | | $2,089.30 | $2,691.53 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $1,905.46 / $2,290.87
| Professional | | $346.74 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $2,454.71 / $20,417.38
| Facility | | $263.03 | $2,454.71 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,513.56 / $3,235.94
| Professional | | $1,000.00 | $1,513.56 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $870.96 / $2,290.87
| Facility | | $181.97 | $870.96 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $3,162.28
| Professional | | $1,148.15 | $1,513.56 | $3,162.28 |