- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $6,642.72
| Facility | | $2,326.37 | $2,326.37 | $6,642.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Professional | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.27 / $3,256.93 / $6,836.58
| Facility | | $114.27 | $3,256.93 | $6,836.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,280.76 / $2,280.76 / $2,326.37
| Professional | | $2,280.76 | $2,280.76 | $2,326.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,554.44 / $2,554.44 / $2,554.44
| Facility | | $2,554.44 | $2,554.44 | $2,554.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.44 / $2,554.44 / $2,554.44
| Professional | | $2,554.44 | $2,554.44 | $2,554.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.20 / $56.20 / $56.20
| Facility | | $56.20 | $56.20 | $56.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.44 / $62.44 / $62.44
| Professional | | $62.44 | $62.44 | $62.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.17 / $2,349.17 / $2,584.10
| Professional | | $2,349.17 | $2,349.17 | $2,584.10 |