- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,870.05 / $2,870.05 / $2,870.05
| Facility | | $2,870.05 | $2,870.05 | $2,870.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,870.05 / $3,612.45 / $3,612.45
| Professional | | $2,870.05 | $3,612.45 | $3,612.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,688.42 / $4,361.02 / $4,469.50
| Professional | | $3,688.42 | $4,361.02 | $4,469.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,999.88 / $5,049.87 / $6,349.84
| Professional | | $4,999.88 | $5,049.87 | $6,349.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,021.92 / $3,612.45 / $20,983.29
| Facility | | $2,021.92 | $3,612.45 | $20,983.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.57 / $2,952.05 / $3,280.06
| Professional | | $1,571.57 | $2,952.05 | $3,280.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,600.65 / $2,600.65 / $2,600.65
| Facility | | $2,600.65 | $2,600.65 | $2,600.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.22 / $1,968.04 / $3,280.06
| Professional | | $1,115.22 | $1,968.04 | $3,280.06 |