- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.00 / $2,562.00 / $4,050.00
| Facility | | $900.00 | $2,562.00 | $4,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,837.20 / $2,170.12 / $2,367.41
| Professional | | $1,837.20 | $2,170.12 | $2,367.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,716.48 / $2,282.60 / $2,905.52
| Professional | | $1,716.48 | $2,282.60 | $2,905.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.00 / $1,309.00 / $7,168.00
| Facility | | $385.00 | $1,309.00 | $7,168.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.01 / $2,034.66 / $3,382.53
| Professional | | $1,165.01 | $2,034.66 | $3,382.53 |