- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,819.70 / $10,000.00
| Facility | | $1,318.26 | $1,819.70 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,659.59 / $2,290.87
| Professional | | $1,318.26 | $1,659.59 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,187.76 / $3,981.07
| Facility | | $1,174.90 | $2,187.76 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,019.95 / $4,897.79
| Professional | | $1,819.70 | $3,019.95 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,912.51 / $10,964.78
| Facility | | $5,754.40 | $8,912.51 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,691.53 / $3,630.78
| Professional | | $1,819.70 | $2,691.53 | $3,630.78 |