- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.35 / $1,230.35 / $10,000.00
| Facility | | $1,230.35 | $1,230.35 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.35 / $1,230.35 / $1,259.18
| Professional | | $1,230.35 | $1,230.35 | $1,259.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,428.71 / $2,667.59 / $3,197.85
| Professional | | $2,428.71 | $2,667.59 | $3,197.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.80 / $3,015.09 / $3,893.54
| Professional | | $1,551.80 | $3,015.09 | $3,893.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.35 / $1,611.73 / $3,691.08
| Facility | | $1,230.35 | $1,611.73 | $3,691.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.30 / $2,315.12 / $3,206.53
| Professional | | $1,265.30 | $2,315.12 | $3,206.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.50 / $2,685.25 / $3,433.90
| Professional | | $1,479.50 | $2,685.25 | $3,433.90 |