- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,707.32 / $1,707.32 / $2,048.78
| Facility | | $1,707.32 | $1,707.32 | $2,048.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.35 / $993.35 / $1,190.15
| Professional | | $993.35 | $993.35 | $1,190.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.00 / $971.00 / $971.00
| Professional | | $971.00 | $971.00 | $971.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,615.98 / $8,615.98 / $8,615.98
| Facility | | $8,615.98 | $8,615.98 | $8,615.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,996.65 / $2,996.65 / $2,996.65
| Professional | | $2,996.65 | $2,996.65 | $2,996.65 |