- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,719.76 / $2,719.76 / $2,719.76
| Facility | | $2,719.76 | $2,719.76 | $2,719.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,139.23 / $2,139.23 / $2,719.76
| Professional | | $2,139.23 | $2,139.23 | $2,719.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,194.26 / $4,959.09 / $5,022.75
| Professional | | $4,194.26 | $4,959.09 | $5,022.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,136.25 / $4,177.60 / $5,253.04
| Professional | | $4,136.25 | $4,177.60 | $5,253.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.30 / $2,719.76 / $18,269.96
| Facility | | $224.30 | $2,719.76 | $18,269.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.72 / $1,916.82 / $2,875.23
| Professional | | $1,373.72 | $1,916.82 | $2,875.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.31 / $1,916.82 / $4,107.47
| Professional | | $1,142.31 | $1,916.82 | $4,107.47 |