- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,272.90 / $1,272.90 / $10,000.00
| Facility | | $1,272.90 | $1,272.90 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.40 / $1,272.90 / $1,272.90
| Professional | | $1,256.40 | $1,272.90 | $1,272.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,272.90 / $1,288.92 / $3,818.70
| Facility | | $1,272.90 | $1,288.92 | $3,818.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.64 / $3,417.41 / $4,702.43
| Professional | | $1,915.64 | $3,417.41 | $4,702.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.64 / $3,639.90 / $4,702.43
| Professional | | $1,915.64 | $3,639.90 | $4,702.43 |