- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,248.07 / $8,317.64
| Facility | | $3,981.07 | $5,248.07 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,623.41 / $9,549.93
| Facility | | $4,786.30 | $5,623.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |