- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $532.50 / $788.10 / $1,704.00
| Facility | | $532.50 | $788.10 | $1,704.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.40 / $525.40 / $532.50
| Professional | | $525.40 | $525.40 | $532.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.05 / $865.05 / $1,036.43
| Professional | | $865.05 | $865.05 | $1,036.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.40 / $710.00 / $1,192.80
| Facility | | $525.40 | $710.00 | $1,192.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.20 / $298.20 / $1,065.00
| Professional | | $298.20 | $298.20 | $1,065.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.20 / $298.20 / $710.00
| Professional | | $298.20 | $298.20 | $710.00 |