- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $3,843.95
| Facility | | $960.00 | $1,728.00 | $3,843.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,110.65 / $3,843.95 / $3,843.95
| Professional | | $2,110.65 | $3,843.95 | $3,843.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,682.75 / $3,675.00 / $4,336.50
| Professional | | $2,682.75 | $3,675.00 | $4,336.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.76 / $3,142.64 / $8,073.92
| Professional | | $2,240.76 | $3,142.64 | $8,073.92 |
- 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
- $1,597.27 / $2,457.34 / $3,858.02
| Professional | | $1,597.27 | $2,457.34 | $3,858.02 |