- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $10,000.00
| Facility | | $3,801.89 | $3,801.89 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.11 / $2,951.21 / $8,912.51
| Professional | | $33.11 | $2,951.21 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $269.15 / $269.15
| Facility | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $229.09 / $269.15
| Professional | | $229.09 | $229.09 | $269.15 |