- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $497.25 / $497.25 / $8,500.00
| Facility | | $497.25 | $497.25 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.25 / $497.25 / $500.92
| Professional | | $497.25 | $497.25 | $500.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.48 / $1,023.62 / $1,209.41
| Professional | | $946.48 | $1,023.62 | $1,209.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.13 / $860.01 / $1,388.22
| Professional | | $654.13 | $860.01 | $1,388.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $497.25 / $658.80 / $1,491.75
| Facility | | $497.25 | $658.80 | $1,491.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.37 / $943.38 / $1,274.05
| Professional | | $536.37 | $943.38 | $1,274.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $552.64 / $1,004.80 / $1,274.05
| Professional | | $552.64 | $1,004.80 | $1,274.05 |