- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $270.07 / $270.07 / $10,000.00
| Facility | | $270.07 | $270.07 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.07 / $270.07 / $373.63
| Professional | | $270.07 | $270.07 | $373.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $270.07 / $459.12 / $810.21
| Facility | | $270.07 | $459.12 | $810.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.25 / $753.97 / $1,038.08
| Professional | | $422.25 | $753.97 | $1,038.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.55 / $803.06 / $1,038.08
| Professional | | $465.55 | $803.06 | $1,038.08 |