- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,862.09 / $1,862.09
| Facility | | $1,778.28 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,202.26 / $1,862.09
| Professional | | $870.96 | $1,202.26 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,818.38 / $3,090.30
| Professional | | $2,137.96 | $2,818.38 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,715.35
| Professional | | $2,951.21 | $2,951.21 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,862.09 / $10,232.93
| Facility | | $891.25 | $1,862.09 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,071.52 / $2,290.87
| Professional | | $870.96 | $1,071.52 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $3,162.28 / $3,162.28
| Facility | | $954.99 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,122.02 / $2,754.23
| Professional | | $758.58 | $1,122.02 | $2,754.23 |