- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Facility | | $2,784.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,812.22
| Professional | | $2,784.38 | $2,784.38 | $2,812.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.96 / $2,824.44 / $3,058.55
| Professional | | $2,510.96 | $2,824.44 | $3,058.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.81 / $153.81 / $176.89
| Facility | | $153.81 | $153.81 | $176.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.39 / $117.98 / $2,784.38
| Professional | | $94.39 | $117.98 | $2,784.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $530.00 / $662.70 / $5,011.88
| Facility | | $530.00 | $662.70 | $5,011.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.65 / $530.00 / $575.61
| Professional | | $92.65 | $530.00 | $575.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $3,023.98
| Professional | | $2,784.38 | $2,784.38 | $3,023.98 |