- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.28 / $398.28 / $10,000.00
| Facility | | $398.28 | $398.28 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.28 / $398.28 / $556.63
| Professional | | $398.28 | $398.28 | $556.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.28 / $677.08 / $1,283.93
| Facility | | $398.28 | $677.08 | $1,283.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.45 / $1,069.28 / $1,471.30
| Professional | | $599.45 | $1,069.28 | $1,471.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.34 / $1,061.03 / $1,471.30
| Professional | | $683.34 | $1,061.03 | $1,471.30 |