- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,806.62 / $2,806.62 / $2,806.62
| Facility | | $2,806.62 | $2,806.62 | $2,806.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.10 / $2,806.62 / $3,745.84
| Professional | | $2,326.10 | $2,806.62 | $3,745.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $396.83
| Professional | | $248.35 | $248.35 | $396.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $491.21 / $2,806.62 / $3,745.84
| Facility | | $491.21 | $2,806.62 | $3,745.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.00 / $500.00 / $500.00
| Professional | | $402.00 | $500.00 | $500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.09 / $251.37 / $2,456.55
| Professional | | $169.09 | $251.37 | $2,456.55 |