- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,184.04 / $5,184.04 / $5,184.04
| Facility | | $5,184.04 | $5,184.04 | $5,184.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,661.55 / $1,883.09 / $4,054.18
| Professional | | $1,661.55 | $1,883.09 | $4,054.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,571.19 / $2,698.48 / $3,233.08
| Professional | | $2,571.19 | $2,698.48 | $3,233.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,436.94 / $3,212.33 / $5,640.41
| Professional | | $2,436.94 | $3,212.33 | $5,640.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $3,256.64
| Professional | | $30.00 | $30.00 | $3,256.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.47 / $1,329.24 / $2,328.39
| Professional | | $930.47 | $1,329.24 | $2,328.39 |