- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,777.76 / $2,777.76 / $2,777.76
| Facility | | $2,777.76 | $2,777.76 | $2,777.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,777.76 / $3,394.67 / $3,394.67
| Professional | | $2,777.76 | $3,394.67 | $3,394.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,569.80 / $4,220.77 / $4,325.76
| Professional | | $3,569.80 | $4,220.77 | $4,325.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,698.38 / $4,745.35 / $5,966.94
| Professional | | $4,698.38 | $4,745.35 | $5,966.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,715.22 / $3,351.73 / $18,916.50
| Facility | | $1,715.22 | $3,351.73 | $18,916.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,521.03 / $2,707.02 / $3,549.20
| Professional | | $1,521.03 | $2,707.02 | $3,549.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.11 / $2,707.02 / $3,042.06
| Professional | | $1,203.11 | $2,707.02 | $3,042.06 |