- 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
- $933.25 / $1,000.00 / $2,454.71
| Professional | | $933.25 | $1,000.00 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,071.52 / $1,862.09
| Professional | | $741.31 | $1,071.52 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $954.99
| Facility | | $151.36 | $151.36 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,096.48 / $1,698.24
| Professional | | $870.96 | $1,096.48 | $1,698.24 |