- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.84 / $642.84 / $10,000.00
| Facility | | $642.84 | $642.84 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.84 / $642.84 / $732.56
| Professional | | $642.84 | $642.84 | $732.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.52 / $1,438.78 / $1,703.88
| Professional | | $1,292.52 | $1,438.78 | $1,703.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.74 / $1,617.41 / $2,088.65
| Professional | | $836.74 | $1,617.41 | $2,088.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.84 / $737.21 / $1,928.52
| Facility | | $642.84 | $737.21 | $1,928.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.64 / $1,179.29 / $1,678.14
| Professional | | $658.64 | $1,179.29 | $1,678.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.12 / $1,240.22 / $1,678.14
| Professional | | $682.12 | $1,240.22 | $1,678.14 |