- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,721.92 / $4,721.92 / $4,721.92
| Facility | | $4,721.92 | $4,721.92 | $4,721.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $2,200.00
| Professional | | $1,000.00 | $1,000.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.54 / $1,250.54 / $1,498.28
| Professional | | $1,250.54 | $1,250.54 | $1,498.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,721.92 / $4,721.92 / $4,721.92
| Facility | | $4,721.92 | $4,721.92 | $4,721.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $2,200.00
| Professional | | $1,000.00 | $1,000.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.54 / $1,250.54 / $1,498.28
| Professional | | $1,250.54 | $1,250.54 | $1,498.28 |