- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,760.83 / $7,413.10
| Facility | | $5,888.44 | $6,760.83 | $7,413.10 |
- 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
- $1,348.96 / $1,513.56 / $3,630.78
| Professional | | $1,348.96 | $1,513.56 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,230.27 / $1,995.26
| Professional | | $1,148.15 | $1,230.27 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $3,311.31 / $4,365.16
| Facility | | $436.52 | $3,311.31 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,000.00 / $1,412.54
| Professional | | $741.31 | $1,000.00 | $1,412.54 |