- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,833.57
| Facility | | $960.00 | $1,728.00 | $2,833.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.72 / $2,833.57 / $2,833.57
| Professional | | $1,555.72 | $2,833.57 | $2,833.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,695.06 / $2,322.00 / $2,739.96
| Professional | | $1,695.06 | $2,322.00 | $2,739.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.34 / $2,309.31 / $5,946.57
| Professional | | $1,653.34 | $2,309.31 | $5,946.57 |
- 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
- $1,265.66 / $1,753.85 / $2,838.70
| Professional | | $1,265.66 | $1,753.85 | $2,838.70 |