- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,532.65 / $1,532.65 / $1,532.65
| Facility | | $1,532.65 | $1,532.65 | $1,532.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.71 / $1,073.71 / $1,532.65
| Professional | | $1,073.71 | $1,073.71 | $1,532.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,405.91 / $2,815.47 / $2,864.13
| Professional | | $2,405.91 | $2,815.47 | $2,864.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.50 / $2,098.28 / $2,638.43
| Professional | | $2,077.50 | $2,098.28 | $2,638.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.48 / $1,532.65 / $9,451.79
| Facility | | $110.48 | $1,532.65 | $9,451.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.75 / $1,034.26 / $1,487.62
| Professional | | $710.75 | $1,034.26 | $1,487.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $591.00 / $1,416.78 / $1,487.62
| Professional | | $591.00 | $1,416.78 | $1,487.62 |