- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $922.96 / $922.96 / $10,000.00
| Facility | | $922.96 | $922.96 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.45 / $922.96 / $922.96
| Professional | | $909.45 | $922.96 | $922.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.98 / $1,956.66 / $2,301.94
| Professional | | $1,776.98 | $1,956.66 | $2,301.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.05 / $2,179.42 / $2,814.41
| Professional | | $1,136.05 | $2,179.42 | $2,814.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $922.96 / $1,297.70 / $2,768.88
| Facility | | $922.96 | $1,297.70 | $2,768.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.93 / $1,767.64 / $2,398.84
| Professional | | $954.93 | $1,767.64 | $2,398.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.93 / $1,882.72 / $2,398.84
| Professional | | $954.93 | $1,882.72 | $2,398.84 |