- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,774.45
| Facility | | $960.00 | $1,728.00 | $2,774.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.22 / $2,774.45 / $2,774.45
| Professional | | $1,413.22 | $2,774.45 | $2,774.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.54 / $2,098.00 / $2,475.64
| Professional | | $1,531.54 | $2,098.00 | $2,475.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.82 / $1,839.97 / $4,531.39
| Professional | | $1,321.82 | $1,839.97 | $4,531.39 |
- 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
- $1,144.94 / $1,488.14 / $2,345.04
| Professional | | $1,144.94 | $1,488.14 | $2,345.04 |