- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,010.04 / $1,010.04 / $10,000.00
| Facility | | $1,010.04 | $1,010.04 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.04 / $1,078.64 / $1,496.74
| Professional | | $1,010.04 | $1,078.64 | $1,496.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,024.03 / $2,204.40 / $2,604.51
| Professional | | $2,024.03 | $2,204.40 | $2,604.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.51 / $1,858.55 / $3,000.06
| Professional | | $1,434.51 | $1,858.55 | $3,000.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,010.04 / $1,419.57 / $3,030.12
| Facility | | $1,010.04 | $1,419.57 | $3,030.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.91 / $1,997.19 / $2,721.63
| Professional | | $1,137.91 | $1,997.19 | $2,721.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.57 / $2,127.21 / $2,721.63
| Professional | | $1,254.57 | $2,127.21 | $2,721.63 |