- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.16 / $1,896.31 / $3,136.45
| Professional | | $1,885.16 | $1,896.31 | $3,136.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.33 / $3,996.64 / $7,225.76
| Facility | | $1,106.33 | $3,996.64 | $7,225.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,765.83 / $3,687.78 / $5,024.59
| Professional | | $2,765.83 | $3,687.78 | $5,024.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $2,741.63
| Facility | | $2,741.63 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,001.39 / $5,230.13
| Professional | | $2,001.39 | $2,001.39 | $5,230.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,357.23 / $2,111.23 / $21,030.00
| Facility | | $1,357.23 | $2,111.23 | $21,030.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.12 / $2,102.33 / $3,239.62
| Professional | | $1,900.12 | $2,102.33 | $3,239.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.12 / $2,102.33 / $3,166.86
| Professional | | $1,900.12 | $2,102.33 | $3,166.86 |