- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $935.16 / $935.16 / $8,500.00
| Facility | | $935.16 | $935.16 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.16 / $935.16 / $1,907.21
| Professional | | $935.16 | $935.16 | $1,907.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.49 / $1,322.34 / $1,546.26
| Professional | | $1,247.49 | $1,322.34 | $1,546.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $935.16 / $1,589.77 / $11,346.33
| Facility | | $935.16 | $1,589.77 | $11,346.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.43 / $2,450.78 / $3,454.63
| Professional | | $961.43 | $2,450.78 | $3,454.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.27 / $2,883.36 / $9,869.54
| Professional | | $1,422.27 | $2,883.36 | $9,869.54 |