- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,246.26 / $1,246.26 / $10,000.00
| Facility | | $1,246.26 | $1,246.26 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.54 / $1,246.26 / $1,868.52
| Professional | | $1,111.54 | $1,246.26 | $1,868.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,392.67 / $2,623.91 / $3,145.49
| Professional | | $2,392.67 | $2,623.91 | $3,145.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.92 / $2,852.53 / $3,683.62
| Professional | | $1,518.92 | $2,852.53 | $3,683.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,246.26 / $1,718.67 / $3,738.78
| Facility | | $1,246.26 | $1,718.67 | $3,738.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.32 / $2,310.17 / $3,218.75
| Professional | | $1,353.32 | $2,310.17 | $3,218.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.32 / $2,321.36 / $3,218.75
| Professional | | $1,353.32 | $2,321.36 | $3,218.75 |