- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,644.09 / $2,250.00
| Facility | | $960.00 | $1,644.09 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.73 / $1,644.09 / $1,644.09
| Professional | | $906.73 | $1,644.09 | $1,644.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.07 / $1,359.00 / $1,603.62
| Professional | | $992.07 | $1,359.00 | $1,603.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.00 / $1,344.06 / $3,433.38
| Professional | | $962.00 | $1,344.06 | $3,433.38 |
- 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
- $785.22 / $973.25 / $1,643.73
| Professional | | $785.22 | $973.25 | $1,643.73 |