- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,045.20 / $1,045.20 / $10,000.00
| Facility | | $1,045.20 | $1,045.20 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.13 / $1,045.20 / $1,105.25
| Professional | | $980.13 | $1,045.20 | $1,105.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,000.87 / $2,177.19 / $2,609.98
| Professional | | $2,000.87 | $2,177.19 | $2,609.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.73 / $2,430.19 / $3,138.25
| Professional | | $1,255.73 | $2,430.19 | $3,138.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,045.20 / $1,455.53 / $3,135.60
| Facility | | $1,045.20 | $1,455.53 | $3,135.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.02 / $1,969.31 / $2,707.58
| Professional | | $1,087.02 | $1,969.31 | $2,707.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.02 / $2,097.52 / $2,707.58
| Professional | | $1,087.02 | $2,097.52 | $2,707.58 |