- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,324.61 / $2,250.00
| Facility | | $960.00 | $1,324.61 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.76 / $1,324.61 / $1,643.67
| Professional | | $743.76 | $1,324.61 | $1,643.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.60 / $789.86 / $932.03
| Professional | | $576.60 | $789.86 | $932.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.63 / $1,119.13 / $2,687.29
| Professional | | $788.63 | $1,119.13 | $2,687.29 |
- 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
- $610.64 / $854.38 / $1,302.69
| Professional | | $610.64 | $854.38 | $1,302.69 |