- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,100.55 / $1,100.55 / $10,000.00
| Facility | | $1,100.55 | $1,100.55 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.97 / $1,100.55 / $1,147.69
| Professional | | $1,023.97 | $1,100.55 | $1,147.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,242.82 / $2,467.21 / $2,892.93
| Professional | | $2,242.82 | $2,467.21 | $2,892.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.93 / $2,724.95 / $3,629.64
| Professional | | $1,363.93 | $2,724.95 | $3,629.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,100.55 / $1,427.00 / $1,897.70
| Facility | | $1,100.55 | $1,427.00 | $1,897.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.31 / $2,075.57 / $2,847.64
| Professional | | $1,156.31 | $2,075.57 | $2,847.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.31 / $2,075.57 / $2,847.64
| Professional | | $1,156.31 | $2,075.57 | $2,847.64 |