- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $548.03 / $548.03 / $9,500.00
| Facility | | $548.03 | $548.03 | $9,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.47 / $548.03 / $548.03
| Professional | | $376.47 | $548.03 | $548.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.34 / $548.03 / $1,644.09
| Facility | | $511.34 | $548.03 | $1,644.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.77 / $1,529.93 / $2,106.53
| Professional | | $856.77 | $1,529.93 | $2,106.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.77 / $1,629.54 / $2,197.48
| Professional | | $856.77 | $1,629.54 | $2,197.48 |