- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,109.84 / $3,490.20 / $3,490.20
| Facility | | $2,109.84 | $3,490.20 | $3,490.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,109.84 / $2,482.17
| Professional | | $2,068.46 | $2,109.84 | $2,482.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.19 / $172.74 / $243.30
| Professional | | $136.19 | $172.74 | $243.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,951.39 / $1,951.39 / $2,068.46
| Facility | | $1,951.39 | $1,951.39 | $2,068.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,634.37
| Professional | | $2,068.46 | $2,068.46 | $2,634.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $474.00 / $2,482.16 / $5,196.14
| Facility | | $474.00 | $2,482.16 | $5,196.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,220.57 / $2,220.57 / $11,634.00
| Professional | | $2,220.57 | $2,220.57 | $11,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,529.73
| Professional | | $2,068.46 | $2,068.46 | $2,529.73 |