- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.85 / $1,366.50 / $1,920.51
| Professional | | $1,018.85 | $1,366.50 | $1,920.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $797.23 / $2,880.00 / $5,206.92
| Facility | | $797.23 | $2,880.00 | $5,206.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,993.09 / $2,657.45 / $3,620.77
| Professional | | $1,993.09 | $2,657.45 | $3,620.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,654.54 / $1,654.54 / $1,654.54
| Facility | | $1,654.54 | $1,654.54 | $1,654.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.81 / $1,207.81 / $2,780.63
| Professional | | $1,207.81 | $1,207.81 | $2,780.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $733.52 / $2,029.01 / $12,123.54
| Facility | | $733.52 | $2,029.01 | $12,123.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.93 / $1,136.22 / $1,750.88
| Professional | | $1,026.93 | $1,136.22 | $1,750.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.93 / $1,136.22 / $1,711.55
| Professional | | $1,026.93 | $1,136.22 | $1,711.55 |