- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $689.23 / $689.23 / $10,000.00
| Facility | | $689.23 | $689.23 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.23 / $689.23 / $776.98
| Professional | | $689.23 | $689.23 | $776.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $689.23 / $689.23 / $2,067.69
| Facility | | $689.23 | $689.23 | $2,067.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.97 / $1,226.09 / $2,546.25
| Professional | | $796.97 | $1,226.09 | $2,546.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.97 / $1,692.74 / $2,546.25
| Professional | | $796.97 | $1,692.74 | $2,546.25 |