- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,111.09 / $3,111.09 / $3,111.09
| Facility | | $3,111.09 | $3,111.09 | $3,111.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,111.09 / $3,802.05 / $3,802.05
| Professional | | $3,111.09 | $3,802.05 | $3,802.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,998.18 / $4,727.26 / $4,844.85
| Professional | | $3,998.18 | $4,727.26 | $4,844.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,262.38 / $5,315.00 / $6,683.22
| Professional | | $5,262.38 | $5,315.00 | $6,683.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,921.04 / $3,753.95 / $21,186.55
| Facility | | $1,921.04 | $3,753.95 | $21,186.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,703.56 / $3,031.88 / $3,975.13
| Professional | | $1,703.56 | $3,031.88 | $3,975.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.38 / $2,021.25 / $3,407.11
| Professional | | $1,145.38 | $2,021.25 | $3,407.11 |