- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,328.27 / $1,328.27 / $10,000.00
| Facility | | $1,328.27 | $1,328.27 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.27 / $1,829.31 / $1,829.31
| Professional | | $1,328.27 | $1,829.31 | $1,829.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,328.27 / $2,198.75 / $3,984.81
| Facility | | $1,328.27 | $2,198.75 | $3,984.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,816.91 / $3,217.63 / $4,906.96
| Professional | | $1,816.91 | $3,217.63 | $4,906.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,008.00 / $11,008.00 / $11,008.00
| Facility | | $11,008.00 | $11,008.00 | $11,008.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.76 / $2,951.13 / $4,634.47
| Professional | | $1,807.76 | $2,951.13 | $4,634.47 |