- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,786.58 / $2,786.58 / $2,786.58
| Facility | | $2,786.58 | $2,786.58 | $2,786.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,786.58 / $2,786.58 / $3,483.23
| Professional | | $2,786.58 | $2,786.58 | $3,483.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.01 / $464.43 / $464.43
| Professional | | $316.01 | $464.43 | $464.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $6,067.50
| Professional | | $248.35 | $248.35 | $6,067.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.83 / $1,463.85 / $3,657.39
| Facility | | $320.83 | $1,463.85 | $3,657.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $253.56 / $2,621.85
| Professional | | $151.16 | $253.56 | $2,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $252.81 / $2,561.78
| Professional | | $151.16 | $252.81 | $2,561.78 |