- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $415.12 / $415.12 / $8,500.00
| Facility | | $415.12 | $415.12 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.12 / $531.46 / $538.09
| Professional | | $415.12 | $531.46 | $538.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $415.12 / $539.66 / $1,245.35
| Facility | | $415.12 | $539.66 | $1,245.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.89 / $1,070.67 / $1,453.18
| Professional | | $648.89 | $1,070.67 | $1,453.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.89 / $763.93 / $1,331.11
| Professional | | $648.89 | $763.93 | $1,331.11 |