- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.34 / $1,321.34 / $10,000.00
| Facility | | $1,321.34 | $1,321.34 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.34 / $1,321.34 / $2,060.17
| Professional | | $1,321.34 | $1,321.34 | $2,060.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.34 / $2,246.28 / $3,964.02
| Facility | | $1,321.34 | $2,246.28 | $3,964.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,926.10 / $3,531.28 / $4,934.04
| Professional | | $1,926.10 | $3,531.28 | $4,934.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.59 / $3,761.18 / $4,934.04
| Professional | | $2,123.59 | $3,761.18 | $4,934.04 |