- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,057.55 / $1,057.55 / $10,000.00
| Facility | | $1,057.55 | $1,057.55 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.27 / $1,051.51 / $1,681.30
| Professional | | $924.27 | $1,051.51 | $1,681.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,135.64 / $2,349.31 / $2,754.69
| Professional | | $2,135.64 | $2,349.31 | $2,754.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.41 / $2,580.65 / $3,437.43
| Professional | | $1,353.41 | $2,580.65 | $3,437.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,057.55 / $1,469.91 / $1,913.34
| Facility | | $1,057.55 | $1,469.91 | $1,913.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.17 / $1,955.49 / $2,733.02
| Professional | | $1,115.17 | $1,955.49 | $2,733.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.17 / $1,955.49 / $2,453.37
| Professional | | $1,115.17 | $1,955.49 | $2,453.37 |