- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,305.68 / $2,250.00
| Facility | | $960.00 | $1,305.68 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.52 / $1,305.68 / $1,305.68
| Professional | | $723.52 | $1,305.68 | $1,305.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.83 / $1,071.00 / $1,263.78
| Professional | | $781.83 | $1,071.00 | $1,263.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.19 / $1,062.66 / $2,729.03
| Professional | | $768.19 | $1,062.66 | $2,729.03 |
- 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
- $623.09 / $830.78 / $1,304.32
| Professional | | $623.09 | $830.78 | $1,304.32 |