- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Facility | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,485.96 / $2,575.82
| Professional | | $2,396.11 | $2,485.96 | $2,575.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Facility | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Professional | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $262.33 / $2,575.82 / $3,258.71
| Facility | | $262.33 | $2,575.82 | $3,258.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.31 / $324.31 / $354.96
| Professional | | $324.31 | $324.31 | $354.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $2,000.00 / $3,900.00
| Professional | | $30.00 | $2,000.00 | $3,900.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.54 / $330.54 / $5,132.68
| Facility | | $330.54 | $330.54 | $5,132.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $2,495.94 / $2,495.94
| Professional | | $2,495.94 | $2,495.94 | $2,495.94 |