- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,769.71 / $2,769.71 / $2,769.71
| Facility | | $2,769.71 | $2,769.71 | $2,769.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.52 / $2,033.09 / $2,769.71
| Professional | | $847.52 | $2,033.09 | $2,769.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,997.84 / $2,997.84 / $2,997.84
| Professional | | $2,997.84 | $2,997.84 | $2,997.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,406.76
| Facility | | $1,406.76 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.80 / $1,406.76 / $4,485.93
| Professional | | $218.80 | $1,406.76 | $4,485.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $847.52 / $2,168.56 / $13,890.95
| Facility | | $847.52 | $2,168.56 | $13,890.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.60 / $1,302.91 / $2,215.73
| Professional | | $868.60 | $1,302.91 | $2,215.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.60 / $1,249.49 / $2,082.02
| Professional | | $868.60 | $1,249.49 | $2,082.02 |