- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,805.74 / $2,805.74 / $6,907.00
| Facility | | $2,805.74 | $2,805.74 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.05 / $1,091.73 / $1,091.73
| Professional | | $956.05 | $1,091.73 | $1,091.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,881.82 / $4,881.82 / $4,881.82
| Facility | | $4,881.82 | $4,881.82 | $4,881.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.57 / $1,133.02 / $2,001.75
| Professional | | $962.57 | $1,133.02 | $2,001.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.00 / $2,783.00 / $2,783.00
| Facility | | $2,783.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $921.30 / $1,223.05 / $2,490.94
| Professional | | $921.30 | $1,223.05 | $2,490.94 |