- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,252.38
| Facility | | $960.00 | $1,728.00 | $2,252.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.79 / $2,252.38 / $2,252.38
| Professional | | $1,239.79 | $2,252.38 | $2,252.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,354.88 / $1,856.00 / $2,190.08
| Professional | | $1,354.88 | $1,856.00 | $2,190.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.73 / $1,627.76 / $4,965.21
| Professional | | $1,278.73 | $1,627.76 | $4,965.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,783.00 / $5,201.00
| Facility | | $650.00 | $1,783.00 | $5,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.94 / $1,475.26 / $2,246.03
| Professional | | $1,072.94 | $1,475.26 | $2,246.03 |