- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $935.66 / $935.66 / $8,500.00
| Facility | | $935.66 | $935.66 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.66 / $935.66 / $2,221.05
| Professional | | $935.66 | $935.66 | $2,221.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.49 / $1,322.34 / $1,478.64
| Professional | | $1,247.49 | $1,322.34 | $1,478.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $935.66 / $1,590.62 / $7,574.75
| Facility | | $935.66 | $1,590.62 | $7,574.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.49 / $2,452.10 / $3,456.54
| Professional | | $961.49 | $2,452.10 | $3,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.34 / $2,929.10 / $3,456.54
| Professional | | $1,422.34 | $2,929.10 | $3,456.54 |