- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $966.18 / $966.18 / $8,500.00
| Facility | | $966.18 | $966.18 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.18 / $966.18 / $1,556.76
| Professional | | $966.18 | $966.18 | $1,556.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,511.63 / $1,511.63 / $1,889.53
| Professional | | $1,511.63 | $1,511.63 | $1,889.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $966.18 / $1,642.51 / $2,898.54
| Facility | | $966.18 | $1,642.51 | $2,898.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.05 / $2,660.62 / $3,569.35
| Professional | | $1,454.05 | $2,660.62 | $3,569.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,646.11 / $2,833.84 / $3,569.35
| Professional | | $1,646.11 | $2,833.84 | $3,569.35 |