- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $351.57 / $351.57 / $10,000.00
| Facility | | $351.57 | $351.57 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.57 / $351.57 / $485.80
| Professional | | $351.57 | $351.57 | $485.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $351.57 / $597.66 / $1,174.56
| Facility | | $351.57 | $597.66 | $1,174.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.64 / $981.48 / $1,351.37
| Professional | | $549.64 | $981.48 | $1,351.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.64 / $972.86 / $1,351.37
| Professional | | $549.64 | $972.86 | $1,351.37 |