- 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
- $933.25 / $1,096.48 / $2,818.38
| Professional | | $933.25 | $1,096.48 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,122.02 / $1,949.84
| Professional | | $831.76 | $1,122.02 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Professional | | $1,071.52 | $1,071.52 | $1,071.52 |
- 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
- $933.25 / $1,174.90 / $1,905.46
| Professional | | $933.25 | $1,174.90 | $1,905.46 |