- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $628.69 / $628.69 / $10,000.00
| Facility | | $628.69 | $628.69 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.69 / $628.69 / $855.64
| Professional | | $628.69 | $628.69 | $855.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $628.69 / $1,068.77 / $1,886.07
| Facility | | $628.69 | $1,068.77 | $1,886.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.27 / $1,701.22 / $2,322.48
| Professional | | $946.27 | $1,701.22 | $2,322.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $996.59 / $1,770.35 / $2,322.48
| Professional | | $996.59 | $1,770.35 | $2,322.48 |