- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,923.67 / $4,923.67 / $4,923.67
| Facility | | $4,923.67 | $4,923.67 | $4,923.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.80 / $261.80 / $4,923.67
| Professional | | $261.80 | $261.80 | $4,923.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.16 / $1,339.14 / $2,244.44
| Facility | | $1,107.16 | $1,339.14 | $2,244.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.38 / $383.38 / $522.64
| Professional | | $383.38 | $383.38 | $522.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |