- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $7,244.36
| Facility | | $4,897.79 | $4,897.79 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,023.29 / $2,344.23
| Professional | | $870.96 | $1,023.29 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,122.02 / $1,778.28
| Professional | | $831.76 | $1,122.02 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,479.11
| Facility | | $1,000.00 | $1,000.00 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,148.15 / $1,698.24
| Professional | | $870.96 | $1,148.15 | $1,698.24 |