- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,088.16 / $1,088.16 / $10,000.00
| Facility | | $1,088.16 | $1,088.16 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.58 / $1,088.16 / $1,088.16
| Professional | | $1,025.58 | $1,088.16 | $1,088.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.87 / $2,276.54 / $2,729.07
| Professional | | $2,092.87 | $2,276.54 | $2,729.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.75 / $2,542.92 / $3,283.83
| Professional | | $1,312.75 | $2,542.92 | $3,283.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,088.16 / $1,522.80 / $3,264.48
| Facility | | $1,088.16 | $1,522.80 | $3,264.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.59 / $2,174.81 / $2,820.35
| Professional | | $1,129.59 | $2,174.81 | $2,820.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.54 / $2,316.40 / $2,820.35
| Professional | | $1,108.54 | $2,316.40 | $2,820.35 |