- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.00 / $7,265.00 / $19,413.06
| Facility | | $6,907.00 | $7,265.00 | $19,413.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.37 / $1,005.24 / $1,005.24
| Professional | | $863.37 | $1,005.24 | $1,005.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.33 / $1,105.13 / $1,252.44
| Professional | | $817.33 | $1,105.13 | $1,252.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,980.09 / $7,980.09 / $7,980.09
| Facility | | $7,980.09 | $7,980.09 | $7,980.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.28 / $1,001.82 / $2,313.46
| Professional | | $777.28 | $1,001.82 | $2,313.46 |