- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,193.58 / $1,193.58 / $10,000.00
| Facility | | $1,193.58 | $1,193.58 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.84 / $1,193.58 / $1,193.58
| Professional | | $1,064.84 | $1,193.58 | $1,193.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,289.73 / $2,492.15 / $2,987.54
| Professional | | $2,289.73 | $2,492.15 | $2,987.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.62 / $2,780.64 / $3,590.79
| Professional | | $1,450.62 | $2,780.64 | $3,590.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,193.58 / $1,665.42 / $3,580.74
| Facility | | $1,193.58 | $1,665.42 | $3,580.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.68 / $2,242.86 / $3,093.03
| Professional | | $1,239.68 | $2,242.86 | $3,093.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.68 / $2,388.88 / $3,093.03
| Professional | | $1,239.68 | $2,388.88 | $3,093.03 |