- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,742.88
| Facility | | $960.00 | $1,728.00 | $2,742.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,209.82 / $1,595.76 / $2,742.88
| Professional | | $1,209.82 | $1,595.76 | $2,742.88 |
- 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
- $1,246.10 / $1,792.35 / $2,048.40
| Professional | | $1,246.10 | $1,792.35 | $2,048.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.34 / $1,711.27 / $4,747.09
| Professional | | $1,205.34 | $1,711.27 | $4,747.09 |
- 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
- $1,069.70 / $1,384.52 / $2,283.73
| Professional | | $1,069.70 | $1,384.52 | $2,283.73 |