- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,058.80 / $1,058.80 / $10,000.00
| Facility | | $1,058.80 | $1,058.80 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.80 / $1,093.21 / $1,633.35
| Professional | | $1,058.80 | $1,093.21 | $1,633.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,076.78 / $2,257.01 / $2,666.68
| Professional | | $2,076.78 | $2,257.01 | $2,666.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.72 / $1,935.01 / $3,123.48
| Professional | | $1,301.72 | $1,935.01 | $3,123.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,058.80 / $1,468.50 / $3,176.40
| Facility | | $1,058.80 | $1,468.50 | $3,176.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.38 / $1,999.11 / $2,499.56
| Professional | | $1,135.38 | $1,999.11 | $2,499.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.08 / $2,129.26 / $2,499.56
| Professional | | $1,171.08 | $2,129.26 | $2,499.56 |