- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $491.01 / $491.01 / $8,500.00
| Facility | | $491.01 | $491.01 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.26 / $491.01 / $613.76
| Professional | | $317.26 | $491.01 | $613.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $491.01 / $751.46 / $901.75
| Facility | | $491.01 | $751.46 | $901.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.25 / $964.49 / $1,360.20
| Professional | | $553.25 | $964.49 | $1,360.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.25 / $964.49 / $1,217.15
| Professional | | $553.25 | $964.49 | $1,217.15 |