- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,372.31 / $5,372.31 / $5,372.31
| Facility | | $5,372.31 | $5,372.31 | $5,372.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,372.31 / $6,082.33 / $6,082.33
| Professional | | $5,372.31 | $6,082.33 | $6,082.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,904.19 / $8,163.19 / $8,366.26
| Professional | | $6,904.19 | $8,163.19 | $8,366.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,418.37 / $8,502.56 / $10,691.34
| Professional | | $8,418.37 | $8,502.56 | $10,691.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,923.64 / $5,642.82 / $35,737.98
| Facility | | $3,923.64 | $5,642.82 | $35,737.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,941.74 / $5,266.49 / $5,971.73
| Professional | | $2,941.74 | $5,266.49 | $5,971.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.66 / $5,266.49 / $5,883.48
| Professional | | $2,340.66 | $5,266.49 | $5,883.48 |