- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,531.55 / $2,531.55 / $2,531.55
| Facility | | $2,531.55 | $2,531.55 | $2,531.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,101.62 / $2,101.62 / $2,531.55
| Professional | | $2,101.62 | $2,101.62 | $2,531.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,714.06 / $4,346.30 / $4,421.42
| Professional | | $3,714.06 | $4,346.30 | $4,421.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,768.75 / $3,806.44 / $4,786.31
| Professional | | $3,768.75 | $3,806.44 | $4,786.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.04 / $2,531.55 / $16,659.23
| Facility | | $164.04 | $2,531.55 | $16,659.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.97 / $1,450.35 / $2,175.53
| Professional | | $925.97 | $1,450.35 | $2,175.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.71 / $1,450.35 / $2,175.53
| Professional | | $737.71 | $1,450.35 | $2,175.53 |