- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,085.82 / $2,085.82 / $2,867.91
| Facility | | $2,085.82 | $2,085.82 | $2,867.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,840.07 / $3,341.25
| Professional | | $2,784.38 | $2,840.07 | $3,341.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.19 / $109.23 / $2,784.38
| Professional | | $91.19 | $109.23 | $2,784.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,626.77 / $2,626.77 / $2,784.38
| Facility | | $2,626.77 | $2,626.77 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $3,546.14
| Professional | | $2,784.38 | $2,784.38 | $3,546.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.23 / $573.20 / $1,490.31
| Facility | | $166.23 | $573.20 | $1,490.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.31 / $530.00 / $630.70
| Professional | | $430.31 | $530.00 | $630.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.06 / $124.06 / $124.06
| Facility | | $124.06 | $124.06 | $124.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $3,405.30
| Professional | | $2,784.38 | $2,784.38 | $3,405.30 |