- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,300.76 / $3,300.76 / $3,300.76
| Facility | | $3,300.76 | $3,300.76 | $3,300.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,741.45 / $2,741.45 / $3,300.76
| Professional | | $2,741.45 | $2,741.45 | $3,300.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,153.77 / $6,031.09 / $6,135.33
| Professional | | $5,153.77 | $6,031.09 | $6,135.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,231.25 / $5,283.56 / $6,643.69
| Professional | | $5,231.25 | $5,283.56 | $6,643.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.45 / $3,300.76 / $24,693.27
| Facility | | $2,741.45 | $3,300.76 | $24,693.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,886.15 / $2,767.87 / $4,151.81
| Professional | | $1,886.15 | $2,767.87 | $4,151.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.92 / $3,248.24 / $4,151.81
| Professional | | $1,508.92 | $3,248.24 | $4,151.81 |