- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,700.11 / $2,700.11 / $2,700.11
| Facility | | $2,700.11 | $2,700.11 | $2,700.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,109.98 / $2,700.11 / $2,700.11
| Professional | | $2,109.98 | $2,700.11 | $2,700.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,193.72 / $5,550.51 / $6,167.23
| Professional | | $4,193.72 | $5,550.51 | $6,167.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,970.76 / $4,680.50 / $5,043.37
| Facility | | $1,970.76 | $4,680.50 | $5,043.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.33 / $4,791.22 / $5,043.37
| Professional | | $2,017.33 | $4,791.22 | $5,043.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,802.84 / $2,802.84 / $3,886.30
| Facility | | $2,802.84 | $2,802.84 | $3,886.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.41 / $2,802.84 / $3,795.22
| Professional | | $2,382.41 | $2,802.84 | $3,795.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.86 / $2,423.54 / $3,448.38
| Professional | | $1,491.86 | $2,423.54 | $3,448.38 |