- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $4,365.16
| Professional | | $2,884.03 | $3,019.95 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,309.57 / $8,511.38
| Facility | | $5,370.32 | $6,309.57 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Professional | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $8,511.38
| Professional | | $3,090.30 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,884.03 / $2,951.21
| Facility | | $2,754.23 | $2,884.03 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,019.95 / $3,019.95
| Professional | | $2,951.21 | $3,019.95 | $3,019.95 |