- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,322.08 / $2,322.08 / $2,322.08
| Facility | | $2,322.08 | $2,322.08 | $2,322.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.47 / $1,704.51 / $2,322.08
| Professional | | $710.47 | $1,704.51 | $2,322.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,513.07 / $2,513.07 / $2,513.07
| Professional | | $2,513.07 | $2,513.07 | $2,513.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,436.52 / $1,436.52 / $1,436.52
| Facility | | $1,436.52 | $1,436.52 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.43 / $1,436.52 / $3,759.38
| Professional | | $183.43 | $1,436.52 | $3,759.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $710.47 / $1,818.08 / $11,644.83
| Facility | | $710.47 | $1,818.08 | $11,644.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.29 / $1,092.43 / $1,857.43
| Professional | | $728.29 | $1,092.43 | $1,857.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.47 / $1,047.64 / $1,745.46
| Professional | | $710.47 | $1,047.64 | $1,745.46 |