- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.63 / $912.63 / $10,000.00
| Facility | | $912.63 | $912.63 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.04 / $912.63 / $1,417.93
| Professional | | $827.04 | $912.63 | $1,417.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.05 / $1,948.21 / $2,335.46
| Professional | | $1,775.05 | $1,948.21 | $2,335.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.36 / $2,121.42 / $2,739.51
| Professional | | $1,126.36 | $2,121.42 | $2,739.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.63 / $1,276.79 / $2,737.89
| Facility | | $912.63 | $1,276.79 | $2,737.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.47 / $1,674.22 / $2,358.67
| Professional | | $977.47 | $1,674.22 | $2,358.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.47 / $1,777.22 / $2,358.67
| Professional | | $977.47 | $1,777.22 | $2,358.67 |