- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,969.17 / $2,969.17 / $2,969.17
| Facility | | $2,969.17 | $2,969.17 | $2,969.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,736.53 / $3,977.56 / $3,977.56
| Professional | | $2,736.53 | $3,977.56 | $3,977.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.00 / $462.00 / $462.00
| Professional | | $462.00 | $462.00 | $462.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.20 / $958.51 / $8,011.68
| Professional | | $511.20 | $958.51 | $8,011.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,736.54 / $3,361.32 / $4,929.93
| Facility | | $2,736.54 | $3,361.32 | $4,929.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.00 / $462.00 / $462.00
| Professional | | $462.00 | $462.00 | $462.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,634.40 / $2,899.80 / $5,197.92
| Professional | | $2,634.40 | $2,899.80 | $5,197.92 |