- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,913.47
| Facility | | $960.00 | $1,728.00 | $2,913.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.67 / $2,913.47 / $2,913.47
| Professional | | $1,601.67 | $2,913.47 | $2,913.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,536.65 / $2,105.00 / $2,483.90
| Professional | | $1,536.65 | $2,105.00 | $2,483.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,646.67 / $2,122.34 / $6,382.20
| Professional | | $1,646.67 | $2,122.34 | $6,382.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $5,201.00
| Facility | | $650.00 | $1,754.00 | $5,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.44 / $1,856.58 / $2,928.34
| Professional | | $1,390.44 | $1,856.58 | $2,928.34 |