- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.97 / $224.97 / $8,500.00
| Facility | | $224.97 | $224.97 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.97 / $224.97 / $671.42
| Professional | | $224.97 | $224.97 | $671.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.97 / $674.91 / $1,186.67
| Facility | | $224.97 | $674.91 | $1,186.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.61 / $1,104.30 / $1,557.45
| Professional | | $662.61 | $1,104.30 | $1,557.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $659.26 / $1,121.06 / $1,408.67
| Professional | | $659.26 | $1,121.06 | $1,408.67 |