- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,290.87
| Professional | | $2,089.30 | $2,089.30 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $251.19 / $616.60
| Facility | | $151.36 | $251.19 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $257.04 / $407.38
| Professional | | $177.83 | $257.04 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,089.30 / $2,089.30
| Facility | | $1,949.84 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Professional | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,570.40 / $5,011.87
| Facility | | $2,187.76 | $2,570.40 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $3,467.37
| Professional | | $2,238.72 | $2,238.72 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,623.41 / $5,623.41
| Facility | | $3,467.37 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $2,754.23 / $2,754.23
| Professional | | $125.89 | $2,754.23 | $2,754.23 |