- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $945.75 / $945.75 / $8,500.00
| Facility | | $945.75 | $945.75 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.75 / $945.75 / $1,659.07
| Professional | | $945.75 | $945.75 | $1,659.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $945.75 / $1,607.78 / $2,837.25
| Facility | | $945.75 | $1,607.78 | $2,837.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,423.37 / $2,816.63 / $3,493.81
| Professional | | $1,423.37 | $2,816.63 | $3,493.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.00 / $2,960.61 / $3,493.81
| Professional | | $1,650.00 | $2,960.61 | $3,493.81 |