- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $986.74 / $986.74 / $8,500.00
| Facility | | $986.74 | $986.74 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.74 / $986.74 / $1,404.10
| Professional | | $986.74 | $986.74 | $1,404.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $986.74 / $986.74 / $2,960.22
| Facility | | $986.74 | $986.74 | $2,960.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.89 / $2,649.15 / $3,645.21
| Professional | | $1,551.89 | $2,649.15 | $3,645.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.89 / $2,821.62 / $3,645.21
| Professional | | $1,551.89 | $2,821.62 | $3,645.21 |