- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.62 / $867.62 / $8,500.00
| Facility | | $867.62 | $867.62 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.62 / $867.62 / $1,225.79
| Professional | | $867.62 | $867.62 | $1,225.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.62 / $867.62 / $2,602.86
| Facility | | $867.62 | $867.62 | $2,602.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.44 / $2,590.34 / $3,564.66
| Professional | | $1,517.44 | $2,590.34 | $3,564.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.44 / $2,758.98 / $3,564.66
| Professional | | $1,517.44 | $2,758.98 | $3,564.66 |