- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,839.11 / $2,839.11 / $2,839.11
| Facility | | $2,839.11 | $2,839.11 | $2,839.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,387.26 / $2,387.26 / $2,839.11
| Professional | | $2,387.26 | $2,387.26 | $2,839.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,814.65 / $3,327.91 / $3,370.62
| Professional | | $2,814.65 | $3,327.91 | $3,370.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,910.00 / $2,939.10 / $3,695.70
| Professional | | $2,910.00 | $2,939.10 | $3,695.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $554.61 / $2,839.11 / $9,481.87
| Facility | | $554.61 | $2,839.11 | $9,481.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.71 / $205.41 / $2,055.40
| Professional | | $102.71 | $205.41 | $2,055.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.71 / $205.41 / $2,055.40
| Professional | | $102.71 | $205.41 | $2,055.40 |