- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,591.43 / $1,591.43 / $10,000.00
| Facility | | $1,591.43 | $1,591.43 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,591.43 / $1,591.43 / $1,670.41
| Professional | | $1,591.43 | $1,591.43 | $1,670.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,086.22 / $3,375.71 / $4,046.73
| Professional | | $3,086.22 | $3,375.71 | $4,046.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.14 / $3,755.17 / $4,849.26
| Professional | | $1,960.14 | $3,755.17 | $4,849.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,591.43 / $2,038.30 / $4,774.29
| Facility | | $1,591.43 | $2,038.30 | $4,774.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.14 / $2,778.44 / $4,130.45
| Professional | | $1,528.14 | $2,778.44 | $4,130.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.14 / $2,919.48 / $4,130.45
| Professional | | $1,528.14 | $2,919.48 | $4,130.45 |