- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $5,342.87 / $5,926.79
| Facility | | $2,919.60 | $5,342.87 | $5,926.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.48 / $5,342.87 / $5,926.79
| Professional | | $2,306.48 | $5,342.87 | $5,926.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $2,919.60
| Facility | | $2,919.60 | $2,919.60 | $2,919.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $2,919.60
| Professional | | $2,919.60 | $2,919.60 | $2,919.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $30.00 / $50.00
| Professional | | $21.25 | $30.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $4,963.32
| Professional | | $1,226.23 | $1,751.76 | $4,963.32 |