- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $10,000.00
| Facility | | $1,258.93 | $1,258.93 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,258.93 / $2,089.30
| Professional | | $1,230.27 | $1,258.93 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,288.25 / $3,801.89
| Facility | | $1,258.93 | $1,288.25 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,311.31 / $4,265.80
| Professional | | $1,905.46 | $3,311.31 | $4,265.80 |
- 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
- $1,778.28 / $3,311.31 / $4,466.84
| Professional | | $1,778.28 | $3,311.31 | $4,466.84 |