- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.72 / $407.72 / $10,000.00
| Facility | | $407.72 | $407.72 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.72 / $407.72 / $563.79
| Professional | | $407.72 | $407.72 | $563.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,287.81 / $2,750.78 / $3,043.02
| Professional | | $2,287.81 | $2,750.78 | $3,043.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.72 / $407.72 / $1,223.16
| Facility | | $407.72 | $407.72 | $1,223.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $666.78 / $1,138.22 / $1,567.25
| Professional | | $666.78 | $1,138.22 | $1,567.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $637.34 / $1,212.32 / $1,567.25
| Professional | | $637.34 | $1,212.32 | $1,567.25 |