- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.97 / $1,221.75 / $2,142.40
| Professional | | $1,210.97 | $1,221.75 | $2,142.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $733.05 / $2,648.14 / $4,787.72
| Facility | | $733.05 | $2,648.14 | $4,787.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.62 / $2,443.50 / $3,329.26
| Professional | | $1,832.62 | $2,443.50 | $3,329.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,638.80 / $1,638.80 / $1,638.80
| Facility | | $1,638.80 | $1,638.80 | $1,638.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.32 / $1,196.32 / $2,937.00
| Professional | | $1,196.32 | $1,196.32 | $2,937.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $783.77 / $2,098.05 / $12,562.85
| Facility | | $783.77 | $2,098.05 | $12,562.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.19 / $1,214.06 / $1,828.81
| Professional | | $1,096.19 | $1,214.06 | $1,828.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.94 / $1,203.23 / $1,376.73
| Facility | | $1.94 | $1,203.23 | $1,376.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.19 / $1,214.06 / $1,828.81
| Professional | | $1,096.19 | $1,214.06 | $1,828.81 |