- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $810.35 / $810.35 / $10,000.00
| Facility | | $810.35 | $810.35 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.35 / $810.35 / $1,120.08
| Professional | | $810.35 | $810.35 | $1,120.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $810.35 / $1,377.60 / $2,431.05
| Facility | | $810.35 | $1,377.60 | $2,431.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.74 / $2,262.19 / $3,114.88
| Professional | | $1,266.74 | $2,262.19 | $3,114.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.62 / $2,296.94 / $3,114.88
| Professional | | $1,396.62 | $2,296.94 | $3,114.88 |