- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.76 / $1,318.76 / $10,000.00
| Facility | | $1,318.76 | $1,318.76 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.76 / $1,360.77 / $1,868.74
| Professional | | $1,318.76 | $1,360.77 | $1,868.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,455.08 / $2,692.00 / $3,180.62
| Professional | | $2,455.08 | $2,692.00 | $3,180.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,780.01 / $2,325.15 / $3,753.25
| Professional | | $1,780.01 | $2,325.15 | $3,753.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.76 / $1,617.34 / $3,956.28
| Facility | | $1,318.76 | $1,617.34 | $3,956.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.65 / $2,436.69 / $3,380.26
| Professional | | $1,422.65 | $2,436.69 | $3,380.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,557.20 / $2,595.34 / $3,090.78
| Professional | | $1,557.20 | $2,595.34 | $3,090.78 |