- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.52 / $385.52 / $8,500.00
| Facility | | $385.52 | $385.52 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.30 / $385.52 / $385.52
| Professional | | $323.30 | $385.52 | $385.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.52 / $468.32 / $1,156.56
| Facility | | $385.52 | $468.32 | $1,156.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.70 / $1,076.27 / $1,481.91
| Professional | | $602.70 | $1,076.27 | $1,481.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,060.74 / $7,060.74 / $7,060.74
| Facility | | $7,060.74 | $7,060.74 | $7,060.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.49 / $1,146.33 / $1,481.91
| Professional | | $630.49 | $1,146.33 | $1,481.91 |