- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,932.70 / $2,006.39 / $2,022.64
| Facility | | $1,932.70 | $2,006.39 | $2,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,792.34 / $1,851.62 / $2,086.44
| Professional | | $1,792.34 | $1,851.62 | $2,086.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.75 / $2,490.73 / $2,984.18
| Professional | | $2,349.75 | $2,490.73 | $2,984.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.40 / $345.40 / $345.40
| Professional | | $345.40 | $345.40 | $345.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $2,500.00 / $2,500.00
| Professional | | $100.00 | $2,500.00 | $2,500.00 |