- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,525.14 / $1,525.14 / $10,000.00
| Facility | | $1,525.14 | $1,525.14 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.14 / $1,560.58 / $2,593.05
| Professional | | $1,525.14 | $1,560.58 | $2,593.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,010.31 / $3,306.66 / $3,963.96
| Professional | | $3,010.31 | $3,306.66 | $3,963.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,924.75 / $3,737.20 / $4,826.05
| Professional | | $1,924.75 | $3,737.20 | $4,826.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,525.14 / $2,065.30 / $4,575.42
| Facility | | $1,525.14 | $2,065.30 | $4,575.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,568.81 / $2,860.28 / $3,974.31
| Professional | | $1,568.81 | $2,860.28 | $3,974.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,568.81 / $3,046.50 / $3,974.31
| Professional | | $1,568.81 | $3,046.50 | $3,974.31 |