- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,767.64
| Facility | | $960.00 | $1,728.00 | $2,767.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.83 / $1,609.84 / $2,767.64
| Professional | | $1,220.83 | $1,609.84 | $2,767.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,591.87 / $5,572.46 / $7,496.74
| Facility | | $4,591.87 | $5,572.46 | $7,496.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.71 / $1,813.35 / $2,072.40
| Professional | | $1,260.71 | $1,813.35 | $2,072.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.91 / $1,731.32 / $4,745.09
| Professional | | $1,216.91 | $1,731.32 | $4,745.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $4,083.00
| Facility | | $650.00 | $1,754.00 | $4,083.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.33 / $1,440.34 / $2,361.71
| Professional | | $1,078.33 | $1,440.34 | $2,361.71 |