- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,239.18 / $1,239.18 / $10,000.00
| Facility | | $1,239.18 | $1,239.18 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.18 / $1,239.18 / $2,028.65
| Professional | | $1,239.18 | $1,239.18 | $2,028.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,239.18 / $1,252.58 / $3,717.54
| Facility | | $1,239.18 | $1,252.58 | $3,717.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,956.42 / $3,489.27 / $4,801.57
| Professional | | $1,956.42 | $3,489.27 | $4,801.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,157.02 / $3,716.44 / $4,801.57
| Professional | | $2,157.02 | $3,716.44 | $4,801.57 |