- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.02 / $794.02 / $10,000.00
| Facility | | $794.02 | $794.02 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.60 / $794.02 / $794.02
| Professional | | $768.60 | $794.02 | $794.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,553.72 / $1,697.37 / $2,034.77
| Professional | | $1,553.72 | $1,697.37 | $2,034.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.61 / $1,896.78 / $2,449.42
| Professional | | $978.61 | $1,896.78 | $2,449.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.02 / $1,133.08 / $2,382.06
| Facility | | $794.02 | $1,133.08 | $2,382.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.20 / $1,468.85 / $2,059.42
| Professional | | $823.20 | $1,468.85 | $2,059.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.20 / $1,564.48 / $2,059.42
| Professional | | $823.20 | $1,564.48 | $2,059.42 |