- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,975.47 / $1,975.47 / $1,975.47
| Facility | | $1,975.47 | $1,975.47 | $1,975.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.90 / $2,175.34 / $4,167.25
| Professional | | $1,637.90 | $2,175.34 | $4,167.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $6,067.50
| Professional | | $248.35 | $248.35 | $6,067.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,455.76 / $3,455.76 / $3,455.76
| Professional | | $3,455.76 | $3,455.76 | $3,455.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.76 / $264.67 / $1,747.10
| Professional | | $226.76 | $264.67 | $1,747.10 |