- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,862.09 / $2,630.27
| Professional | | $660.69 | $1,862.09 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $1,000.00
| Professional | | $707.95 | $707.95 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $1,698.24 / $2,137.96
| Professional | | $331.13 | $1,698.24 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,513.56 / $4,365.16
| Professional | | $707.95 | $1,513.56 | $4,365.16 |