- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.44 / $972.04 / $1,294.60
| Professional | | $951.44 | $972.04 | $1,294.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.31 / $1,166.25 / $1,847.76
| Professional | | $991.31 | $1,166.25 | $1,847.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.47 / $1,352.24 / $2,081.03
| Professional | | $954.47 | $1,352.24 | $2,081.03 |