- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.53 / $1,201.53 / $10,000.00
| Facility | | $1,201.53 | $1,201.53 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.53 / $1,201.53 / $1,231.58
| Professional | | $1,201.53 | $1,201.53 | $1,231.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,374.02 / $2,606.29 / $3,124.37
| Professional | | $2,374.02 | $2,606.29 | $3,124.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.85 / $2,949.74 / $3,809.15
| Professional | | $1,516.85 | $2,949.74 | $3,809.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.53 / $1,696.14 / $3,604.59
| Facility | | $1,201.53 | $1,696.14 | $3,604.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.99 / $2,259.85 / $3,132.08
| Professional | | $1,234.99 | $2,259.85 | $3,132.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.84 / $2,406.98 / $3,132.08
| Professional | | $1,323.84 | $2,406.98 | $3,132.08 |