- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,800.55 / $2,800.55 / $2,800.55
| Facility | | $2,800.55 | $2,800.55 | $2,800.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,800.55 / $3,189.19 / $3,189.19
| Professional | | $2,800.55 | $3,189.19 | $3,189.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,599.10 / $4,255.41 / $4,361.27
| Professional | | $3,599.10 | $4,255.41 | $4,361.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,414.13 / $4,458.27 / $5,605.94
| Professional | | $4,414.13 | $4,458.27 | $5,605.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,675.88 / $2,979.73 / $17,730.55
| Facility | | $1,675.88 | $2,979.73 | $17,730.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.51 / $2,545.36 / $3,113.03
| Professional | | $1,533.51 | $2,545.36 | $3,113.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.66 / $2,556.73 / $4,036.94
| Professional | | $1,328.66 | $2,556.73 | $4,036.94 |