- 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
- $416.87 / $478.63 / $1,202.26
| Professional | | $416.87 | $478.63 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $501.19 / $851.14
| Professional | | $371.54 | $501.19 | $851.14 |
- 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
- $380.19 / $501.19 / $758.58
| Professional | | $380.19 | $501.19 | $758.58 |