- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,726.35 / $6,726.35 / $6,726.35
| Facility | | $6,726.35 | $6,726.35 | $6,726.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $3,410.17 / $3,973.42
| Facility | | $0.02 | $3,410.17 | $3,973.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,310.73 / $2,310.73 / $2,310.73
| Professional | | $2,310.73 | $2,310.73 | $2,310.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,459.25 / $3,459.25 / $3,459.25
| Facility | | $3,459.25 | $3,459.25 | $3,459.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.84 / $935.84 / $935.84
| Professional | | $935.84 | $935.84 | $935.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.76 / $701.88 / $1,687.20
| Professional | | $577.76 | $701.88 | $1,687.20 |