- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $7,244.36 / $8,128.31
| Facility | | $4,897.79 | $7,244.36 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,174.90 / $3,019.95
| Professional | | $1,023.29 | $1,174.90 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $1,949.84
| Professional | | $891.25 | $1,230.27 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,047.13 / $1,621.81
| Professional | | $707.95 | $1,047.13 | $1,621.81 |