- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,279.58 / $1,279.58 / $10,000.00
| Facility | | $1,279.58 | $1,279.58 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,279.58 / $1,279.58 / $1,410.48
| Professional | | $1,279.58 | $1,279.58 | $1,410.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.00 / $1,389.00 / $1,736.25
| Professional | | $1,389.00 | $1,389.00 | $1,736.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,279.58 / $2,148.39 / $3,838.74
| Facility | | $1,279.58 | $2,148.39 | $3,838.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.74 / $3,431.14 / $4,727.12
| Professional | | $1,925.74 | $3,431.14 | $4,727.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.59 / $3,945.33 / $4,727.12
| Professional | | $2,123.59 | $3,945.33 | $4,727.12 |