- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $351.57 / $351.57 / $8,500.00
| Facility | | $351.57 | $351.57 | $8,500.00 |
- 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 / $1,054.71
| Facility | | $351.57 | $597.66 | $1,054.71 |
- 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
- $606.01 / $1,045.38 / $1,351.37
| Professional | | $606.01 | $1,045.38 | $1,351.37 |