- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.87 / $1,053.85 / $6,930.00
| Professional | | $991.87 | $1,053.85 | $6,930.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.85 / $1,239.83 / $1,239.83
| Facility | | $1,053.85 | $1,239.83 | $1,239.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.85 / $1,239.83 / $1,239.83
| Professional | | $1,053.85 | $1,239.83 | $1,239.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.85 / $1,053.85 / $1,053.85
| Professional | | $1,053.85 | $1,053.85 | $1,053.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.20 / $1,033.20 / $1,033.20
| Professional | | $1,033.20 | $1,033.20 | $1,033.20 |