- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,511.89 / $3,388.44
| Professional | | $2,187.76 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $263.03 / $263.03
| Professional | | $263.03 | $263.03 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $2,454.71 / $4,365.16
| Professional | | $323.59 | $2,454.71 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $346.74 / $562.34
| Professional | | $100.00 | $346.74 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $537.03 / $2,454.71
| Facility | | $208.93 | $537.03 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,187.76 / $3,388.44
| Professional | | $1,412.54 | $2,187.76 | $3,388.44 |