- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,412.02 / $2,250.00
| Facility | | $960.00 | $1,412.02 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.53 / $1,412.02 / $1,752.21
| Professional | | $792.53 | $1,412.02 | $1,752.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.51 / $932.20 / $1,100.00
| Professional | | $680.51 | $932.20 | $1,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.09 / $1,276.30 / $2,938.35
| Professional | | $790.09 | $1,276.30 | $2,938.35 |
- 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
- $651.51 / $921.05 / $1,389.89
| Professional | | $651.51 | $921.05 | $1,389.89 |