- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,268.56 / $1,268.56 / $10,000.00
| Facility | | $1,268.56 | $1,268.56 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.52 / $1,265.34 / $1,315.81
| Professional | | $1,159.52 | $1,265.34 | $1,315.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,568.94 / $2,825.97 / $3,313.61
| Professional | | $2,568.94 | $2,825.97 | $3,313.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.97 / $3,110.62 / $4,143.35
| Professional | | $1,556.97 | $3,110.62 | $4,143.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,268.56 / $1,579.73 / $2,169.05
| Facility | | $1,268.56 | $1,579.73 | $2,169.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.40 / $2,371.34 / $3,279.70
| Professional | | $1,336.40 | $2,371.34 | $3,279.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.40 / $2,365.42 / $3,279.70
| Professional | | $1,336.40 | $2,365.42 | $3,279.70 |