- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $2,041.74
| Facility | | $1,122.02 | $1,548.82 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,513.56 / $2,041.74
| Professional | | $977.24 | $1,513.56 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $4,786.30
| Facility | | $144.54 | $144.54 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,905.46 / $2,630.27
| Professional | | $1,122.02 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $1,445.44 / $2,570.40
| Facility | | $190.55 | $1,445.44 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $1,445.44 / $3,801.89
| Professional | | $190.55 | $1,445.44 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $776.25 / $1,445.44
| Facility | | $100.00 | $776.25 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,122.02 / $1,862.09
| Professional | | $758.58 | $1,122.02 | $1,862.09 |