- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,121.96 / $1,121.96 / $10,000.00
| Facility | | $1,121.96 | $1,121.96 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.12 / $1,121.96 / $1,684.50
| Professional | | $1,004.12 | $1,121.96 | $1,684.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,164.92 / $2,373.78 / $2,845.64
| Professional | | $2,164.92 | $2,373.78 | $2,845.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.19 / $2,578.06 / $3,329.19
| Professional | | $1,374.19 | $2,578.06 | $3,329.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,121.96 / $1,553.96 / $3,365.88
| Facility | | $1,121.96 | $1,553.96 | $3,365.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.89 / $2,101.17 / $2,897.63
| Professional | | $1,230.89 | $2,101.17 | $2,897.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.89 / $2,237.98 / $2,897.63
| Professional | | $1,230.89 | $2,237.98 | $2,897.63 |