- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.54 / $519.54 / $8,980.00
| Facility | | $519.54 | $519.54 | $8,980.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.67 / $519.54 / $850.05
| Professional | | $450.67 | $519.54 | $850.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $900.00 / $1,372.50
| Professional | | $200.00 | $900.00 | $1,372.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.70 / $1,233.45 / $1,975.46
| Facility | | $54.70 | $1,233.45 | $1,975.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.45 / $110.54 / $136.81
| Professional | | $109.45 | $110.54 | $136.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.54 / $519.54 / $2,574.33
| Facility | | $519.54 | $519.54 | $2,574.33 |