- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,560.30 / $1,560.30 / $10,000.00
| Facility | | $1,560.30 | $1,560.30 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.30 / $1,560.30 / $1,575.40
| Professional | | $1,560.30 | $1,560.30 | $1,575.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,064.34 / $3,360.21 / $4,028.16
| Professional | | $3,064.34 | $3,360.21 | $4,028.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,956.70 / $3,778.05 / $4,878.80
| Professional | | $1,956.70 | $3,778.05 | $4,878.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,560.30 / $2,022.54 / $10,659.80
| Facility | | $1,560.30 | $2,022.54 | $10,659.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.04 / $2,920.60 / $4,059.31
| Professional | | $1,611.04 | $2,920.60 | $4,059.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.04 / $3,110.74 / $4,059.31
| Professional | | $1,611.04 | $3,110.74 | $4,059.31 |