- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $312.41 / $312.41 / $8,500.00
| Facility | | $312.41 | $312.41 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.40 / $312.41 / $354.18
| Professional | | $216.40 | $312.41 | $354.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $429.75 / $556.78 / $898.75
| Professional | | $429.75 | $556.78 | $898.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.83 / $312.41 / $937.23
| Facility | | $302.83 | $312.41 | $937.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.12 / $363.03 / $692.81
| Professional | | $224.12 | $363.03 | $692.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.25 / $464.66 / $692.81
| Professional | | $263.25 | $464.66 | $692.81 |