- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $962.47 / $962.47 / $10,000.00
| Facility | | $962.47 | $962.47 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.78 / $962.47 / $999.92
| Professional | | $889.78 | $962.47 | $999.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.87 / $2,146.06 / $2,516.37
| Professional | | $1,950.87 | $2,146.06 | $2,516.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.16 / $2,364.61 / $3,149.66
| Professional | | $1,285.16 | $2,364.61 | $3,149.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $962.47 / $1,330.75 / $1,679.26
| Facility | | $962.47 | $1,330.75 | $1,679.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.40 / $1,765.65 / $2,488.83
| Professional | | $1,013.40 | $1,765.65 | $2,488.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.40 / $1,765.65 / $2,229.48
| Professional | | $1,013.40 | $1,765.65 | $2,229.48 |