- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Facility | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,047.13 / $1,819.70
| Professional | | $891.25 | $1,047.13 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,023.29 / $1,778.28
| Professional | | $776.25 | $1,023.29 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $416.87 / $1,318.26
| Facility | | $100.00 | $416.87 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $954.99 / $1,412.54
| Professional | | $758.58 | $954.99 | $1,412.54 |