- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,470.12 / $2,470.12 / $2,470.12
| Facility | | $2,470.12 | $2,470.12 | $2,470.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,470.12 / $3,210.88 / $3,210.88
| Professional | | $2,470.12 | $3,210.88 | $3,210.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,174.44 / $3,753.31 / $3,846.68
| Professional | | $3,174.44 | $3,753.31 | $3,846.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,444.13 / $4,488.57 / $5,644.04
| Professional | | $4,444.13 | $4,488.57 | $5,644.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.90 / $3,067.25 / $16,444.91
| Facility | | $1,375.90 | $3,067.25 | $16,444.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.58 / $2,325.13 / $2,745.73
| Professional | | $1,352.58 | $2,325.13 | $2,745.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.70 / $2,583.48 / $4,753.47
| Professional | | $1,213.70 | $2,583.48 | $4,753.47 |