- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.19 / $2,126.19 / $4,518.17
| Facility | | $2,126.19 | $2,126.19 | $4,518.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.09 / $244.09 / $2,919.91
| Professional | | $244.09 | $244.09 | $2,919.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.48 / $850.48 / $1,382.03
| Professional | | $850.48 | $850.48 | $1,382.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.19 / $2,126.19 / $2,147.46
| Professional | | $2,126.19 | $2,126.19 | $2,147.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.19 / $2,126.19 / $3,444.44
| Facility | | $2,126.19 | $2,126.19 | $3,444.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.09 / $244.09 / $2,919.91
| Professional | | $244.09 | $244.09 | $2,919.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.72 / $1,275.72 / $3,189.30
| Professional | | $1,275.72 | $1,275.72 | $3,189.30 |