- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,275.21 / $5,275.21 / $5,275.21
| Facility | | $5,275.21 | $5,275.21 | $5,275.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,378.42 / $4,483.93 / $5,275.21
| Professional | | $4,378.42 | $4,483.93 | $5,275.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,903.13 / $1,922.16 / $2,378.91
| Professional | | $1,903.13 | $1,922.16 | $2,378.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,878.50 / $8,023.60 / $13,008.67
| Facility | | $2,878.50 | $8,023.60 | $13,008.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.72 / $5,275.21 / $5,802.73
| Professional | | $2,001.72 | $5,275.21 | $5,802.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,257.66 / $1,855.00 / $3,118.21
| Facility | | $1,257.66 | $1,855.00 | $3,118.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.39 / $2,001.72 / $2,614.65
| Professional | | $1,718.39 | $2,001.72 | $2,614.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,275.21 / $5,275.21 / $5,802.73
| Professional | | $5,275.21 | $5,275.21 | $5,802.73 |