- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,786.30 / $8,511.38
| Facility | | $3,388.44 | $4,786.30 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $8,128.31 / $8,128.31
| Professional | | $3,235.94 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $4,073.80 / $6,760.83
| Facility | | $1,000.00 | $4,073.80 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $6,760.83 / $10,000.00
| Facility | | $831.76 | $6,760.83 | $10,000.00 |