- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $923.21 / $923.21 / $10,000.00
| Facility | | $923.21 | $923.21 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.63 / $923.21 / $1,402.78
| Professional | | $813.63 | $923.21 | $1,402.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.76 / $1,957.36 / $2,346.44
| Professional | | $1,782.76 | $1,957.36 | $2,346.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.81 / $2,131.23 / $2,752.17
| Professional | | $1,146.81 | $2,131.23 | $2,752.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $923.21 / $1,282.38 / $2,769.63
| Facility | | $923.21 | $1,282.38 | $2,769.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.64 / $1,697.90 / $2,384.84
| Professional | | $994.64 | $1,697.90 | $2,384.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.64 / $1,808.44 / $2,384.84
| Professional | | $994.64 | $1,808.44 | $2,384.84 |