- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,888.36 / $2,888.36 / $2,888.36
| Facility | | $2,888.36 | $2,888.36 | $2,888.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,888.36 / $3,289.20 / $3,289.20
| Professional | | $2,888.36 | $3,289.20 | $3,289.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,711.96 / $4,388.85 / $4,498.02
| Professional | | $3,711.96 | $4,388.85 | $4,498.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,552.50 / $4,598.03 / $5,781.68
| Professional | | $4,552.50 | $4,598.03 | $5,781.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,728.44 / $3,073.18 / $18,286.54
| Facility | | $1,728.44 | $3,073.18 | $18,286.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,581.60 / $2,625.18 / $3,210.64
| Professional | | $1,581.60 | $2,625.18 | $3,210.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.75 / $1,980.59 / $3,163.19
| Professional | | $1,166.75 | $1,980.59 | $3,163.19 |