- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,667.96 / $2,250.00
| Facility | | $960.00 | $1,667.96 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.32 / $1,667.96 / $1,887.31
| Professional | | $1,632.32 | $1,667.96 | $1,887.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.76 / $2,260.55 / $3,041.17
| Facility | | $1,862.76 | $2,260.55 | $3,041.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $750.00 / $2,739.00 / $4,402.00
| Facility | | $750.00 | $2,739.00 | $4,402.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,976.80 / $2,675.68 / $4,281.09
| Professional | | $1,976.80 | $2,675.68 | $4,281.09 |