- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,389.47 / $5,389.47 / $5,389.47
| Facility | | $5,389.47 | $5,389.47 | $5,389.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,947.82 / $3,901.86 / $5,389.47
| Professional | | $2,947.82 | $3,901.86 | $5,389.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,277.10 / $6,277.10 / $6,277.10
| Professional | | $6,277.10 | $6,277.10 | $6,277.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $422.50 / $422.50 / $422.50
| Facility | | $422.50 | $422.50 | $422.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.50 / $479.92 / $8,385.94
| Professional | | $422.50 | $479.92 | $8,385.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.06 / $2,872.59 / $5,644.87
| Professional | | $1,915.06 | $2,872.59 | $5,644.87 |