- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $10,000.00 / $10,000.00
| Facility | | $6,309.57 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,548.82 / $1,819.70
| Professional | | $1,445.44 | $1,548.82 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,511.89 / $2,691.53
| Facility | | $2,290.87 | $2,511.89 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Professional | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $3,162.28
| Professional | | $933.25 | $1,318.26 | $3,162.28 |