- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.97 / $224.97 / $8,500.00
| Facility | | $224.97 | $224.97 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.96 / $224.97 / $1,233.74
| Professional | | $224.96 | $224.97 | $1,233.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.97 / $674.91 / $2,404.53
| Facility | | $224.97 | $674.91 | $2,404.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.91 / $2,090.02 / $3,002.06
| Professional | | $1,220.91 | $2,090.02 | $3,002.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.91 / $2,090.02 / $2,686.00
| Professional | | $1,220.91 | $2,090.02 | $2,686.00 |