- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,019.98 / $1,019.98 / $10,000.00
| Facility | | $1,019.98 | $1,019.98 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.19 / $1,019.98 / $1,019.98
| Professional | | $1,008.19 | $1,019.98 | $1,019.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,963.55 / $2,163.10 / $2,588.46
| Professional | | $1,963.55 | $2,163.10 | $2,588.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.86 / $2,413.05 / $3,116.10
| Professional | | $1,256.86 | $2,413.05 | $3,116.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,019.98 / $1,312.34 / $3,059.94
| Facility | | $1,019.98 | $1,312.34 | $3,059.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.18 / $1,956.71 / $2,652.34
| Professional | | $1,054.18 | $1,956.71 | $2,652.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.26 / $2,084.10 / $2,652.34
| Professional | | $1,146.26 | $2,084.10 | $2,652.34 |