- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $469.08 / $469.08 / $8,500.00
| Facility | | $469.08 | $469.08 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.19 / $469.08 / $469.08
| Professional | | $241.19 | $469.08 | $469.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $349.23 / $469.08 / $1,407.24
| Facility | | $349.23 | $469.08 | $1,407.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.13 / $1,309.52 / $1,642.03
| Professional | | $767.13 | $1,309.52 | $1,642.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.59 / $1,309.52 / $1,642.03
| Professional | | $470.59 | $1,309.52 | $1,642.03 |