- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $842.30 / $842.30 / $10,000.00
| Facility | | $842.30 | $842.30 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.60 / $840.54 / $855.65
| Professional | | $773.60 | $840.54 | $855.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.64 / $1,848.78 / $2,167.80
| Professional | | $1,680.64 | $1,848.78 | $2,167.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.54 / $2,054.90 / $2,737.13
| Professional | | $1,028.54 | $2,054.90 | $2,737.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $842.30 / $1,063.89 / $1,431.91
| Facility | | $842.30 | $1,063.89 | $1,431.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.59 / $1,562.33 / $2,182.75
| Professional | | $880.59 | $1,562.33 | $2,182.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.59 / $1,545.20 / $1,937.30
| Professional | | $880.59 | $1,545.20 | $1,937.30 |