- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $530.00 / $530.00 / $530.00
| Facility | | $530.00 | $530.00 | $530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.00 / $3,062.82 / $3,480.47
| Professional | | $530.00 | $3,062.82 | $3,480.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,626.77 / $2,784.38 / $2,784.38
| Facility | | $2,626.77 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Professional | | $2,784.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $530.00 / $3,480.47 / $4,455.00
| Facility | | $530.00 | $3,480.47 | $4,455.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,923.60 / $3,480.48
| Professional | | $2,784.38 | $2,923.60 | $3,480.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.61 / $162.13 / $180.67
| Professional | | $143.61 | $162.13 | $180.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,341.25 / $3,341.25 / $3,341.25
| Professional | | $3,341.25 | $3,341.25 | $3,341.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Professional | | $2,784.38 | $2,784.38 | $2,784.38 |