- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,220.60 / $1,220.60 / $10,000.00
| Facility | | $1,220.60 | $1,220.60 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.39 / $1,220.60 / $1,220.60
| Professional | | $1,147.39 | $1,220.60 | $1,220.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,341.21 / $2,549.21 / $3,055.96
| Professional | | $2,341.21 | $2,549.21 | $3,055.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.37 / $2,843.54 / $3,672.02
| Professional | | $1,470.37 | $2,843.54 | $3,672.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,220.60 / $1,642.12 / $3,661.83
| Facility | | $1,220.60 | $1,642.12 | $3,661.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.19 / $2,281.71 / $3,162.63
| Professional | | $1,268.19 | $2,281.71 | $3,162.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.19 / $2,430.26 / $3,162.63
| Professional | | $1,268.19 | $2,430.26 | $3,162.63 |