- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,162.28 / $4,897.79
| Professional | | $2,691.53 | $3,162.28 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $7,585.78
| Professional | | $6,025.60 | $6,025.60 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $5,248.07 / $7,079.46
| Facility | | $575.44 | $5,248.07 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $269.15 / $741.31
| Professional | | $208.93 | $269.15 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $446.68 / $3,630.78
| Professional | | $213.80 | $446.68 | $3,630.78 |