- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,257.03 / $1,257.03 / $10,000.00
| Facility | | $1,257.03 | $1,257.03 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.03 / $1,257.03 / $1,284.95
| Professional | | $1,257.03 | $1,257.03 | $1,284.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,481.46 / $2,723.96 / $3,265.43
| Professional | | $2,481.46 | $2,723.96 | $3,265.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.99 / $3,078.80 / $3,975.82
| Professional | | $1,584.99 | $3,078.80 | $3,975.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,257.03 / $1,823.13 / $3,771.09
| Facility | | $1,257.03 | $1,823.13 | $3,771.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,293.08 / $2,376.46 / $3,275.58
| Professional | | $1,293.08 | $2,376.46 | $3,275.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.15 / $2,531.17 / $3,275.58
| Professional | | $1,392.15 | $2,531.17 | $3,275.58 |