- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.30 / $3,162.30 / $3,162.30
| Facility | | $3,162.30 | $3,162.30 | $3,162.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.00 / $3,330.96 / $3,951.24
| Professional | | $2,572.00 | $3,330.96 | $3,951.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,585.14 / $4,915.85 / $6,113.52
| Professional | | $4,585.14 | $4,915.85 | $6,113.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $2,673.00
| Facility | | $2,673.00 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.05 / $2,673.00 / $3,931.29
| Professional | | $2,272.05 | $2,673.00 | $3,931.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $4,920.35 / $4,920.35
| Facility | | $64.00 | $4,920.35 | $4,920.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.31 / $1,824.44 / $3,121.10
| Professional | | $1,119.31 | $1,824.44 | $3,121.10 |