- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.51 / $223.51 / $8,500.00
| Facility | | $223.51 | $223.51 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.51 / $223.51 / $308.83
| Professional | | $223.51 | $223.51 | $308.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.51 / $223.51 / $670.53
| Facility | | $223.51 | $223.51 | $670.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.51 / $623.94 / $859.17
| Professional | | $365.51 | $623.94 | $859.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.35 / $618.35 / $859.17
| Professional | | $349.35 | $618.35 | $859.17 |