- 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
- $2,784.38 / $3,034.97 / $3,062.82
| Professional | | $2,784.38 | $3,034.97 | $3,062.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,570.00 / $4,200.00 / $4,200.00
| Professional | | $3,570.00 | $4,200.00 | $4,200.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,626.77 / $2,626.77 / $2,626.77
| Facility | | $2,626.77 | $2,626.77 | $2,626.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $3,940.16 / $3,940.16
| Professional | | $2,784.38 | $3,940.16 | $3,940.16 |
- 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 |