- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,025.60 / $7,762.47
| Facility | | $3,715.35 | $6,025.60 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,630.78 / $4,365.16
| Professional | | $3,019.95 | $3,630.78 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $977.24 / $1,513.56
| Professional | | $11.48 | $977.24 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $9.77 / $1,513.56
| Professional | | $9.77 | $9.77 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,000.00 / $1,318.26
| Professional | | $660.69 | $1,000.00 | $1,318.26 |