- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $740.67 / $740.67 / $10,000.00
| Facility | | $740.67 | $740.67 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.21 / $738.85 / $891.98
| Professional | | $665.21 | $738.85 | $891.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.50 / $1,629.61 / $1,910.82
| Professional | | $1,478.50 | $1,629.61 | $1,910.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.89 / $1,811.85 / $2,413.39
| Professional | | $906.89 | $1,811.85 | $2,413.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $740.67 / $949.48 / $1,259.14
| Facility | | $740.67 | $949.48 | $1,259.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.12 / $1,373.27 / $1,919.60
| Professional | | $774.12 | $1,373.27 | $1,919.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.12 / $1,370.19 / $1,919.60
| Professional | | $774.12 | $1,370.19 | $1,919.60 |