- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,906.93
| Facility | | $960.00 | $1,728.00 | $2,906.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,598.69 / $2,906.93 / $2,906.93
| Professional | | $1,598.69 | $2,906.93 | $2,906.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.69 / $2,953.00 / $3,484.54
| Professional | | $2,155.69 | $2,953.00 | $3,484.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,696.70 / $2,568.56 / $6,081.27
| Professional | | $1,696.70 | $2,568.56 | $6,081.27 |
- 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
- $1,389.63 / $1,945.48 / $2,964.54
| Professional | | $1,389.63 | $1,945.48 | $2,964.54 |