- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $353.51 / $353.51 / $8,500.00
| Facility | | $353.51 | $353.51 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.51 / $353.51 / $497.87
| Professional | | $353.51 | $353.51 | $497.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $353.51 / $600.97 / $1,060.53
| Facility | | $353.51 | $600.97 | $1,060.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.96 / $947.78 / $1,305.98
| Professional | | $531.96 | $947.78 | $1,305.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.21 / $1,009.48 / $1,305.98
| Professional | | $555.21 | $1,009.48 | $1,305.98 |