- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,181.30 / $6,907.00 / $7,412.40
| Facility | | $5,181.30 | $6,907.00 | $7,412.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.88 / $1,319.29 / $1,399.38
| Professional | | $1,102.88 | $1,319.29 | $1,399.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $640.00 / $640.00 / $640.00
| Facility | | $640.00 | $640.00 | $640.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.62 / $1,081.25 / $1,616.35
| Professional | | $1,019.62 | $1,081.25 | $1,616.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.63 / $1,147.63 / $1,147.63
| Professional | | $1,147.63 | $1,147.63 | $1,147.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.86 / $1,097.23 / $2,645.67
| Professional | | $934.86 | $1,097.23 | $2,645.67 |