- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.06 / $3,630.06 / $3,630.06
| Facility | | $3,630.06 | $3,630.06 | $3,630.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.06 / $4,133.89 / $4,133.89
| Professional | | $3,630.06 | $4,133.89 | $4,133.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,665.14 / $5,515.85 / $5,653.06
| Professional | | $4,665.14 | $5,515.85 | $5,653.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,721.75 / $5,778.97 / $7,266.62
| Professional | | $5,721.75 | $5,778.97 | $7,266.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,172.31 / $3,862.38 / $22,982.54
| Facility | | $2,172.31 | $3,862.38 | $22,982.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,987.74 / $3,299.34 / $4,035.10
| Professional | | $1,987.74 | $3,299.34 | $4,035.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.37 / $3,299.34 / $5,232.72
| Professional | | $1,466.37 | $3,299.34 | $5,232.72 |