- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,041.74 / $10,000.00
| Facility | | $1,318.26 | $2,041.74 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,041.74 / $2,187.76
| Professional | | $1,318.26 | $2,041.74 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,238.72 / $3,981.07
| Facility | | $1,318.26 | $2,238.72 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,467.37 / $4,365.16
| Professional | | $1,905.46 | $3,467.37 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,388.44 / $4,677.35
| Professional | | $1,905.46 | $3,388.44 | $4,677.35 |