- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $3,880.71
| Facility | | $960.00 | $1,728.00 | $3,880.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,909.58 / $3,880.71 / $3,880.71
| Professional | | $1,909.58 | $3,880.71 | $3,880.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.61 / $2,557.00 / $3,017.26
| Professional | | $1,866.61 | $2,557.00 | $3,017.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.77 / $2,240.42 / $5,991.45
| Professional | | $1,761.77 | $2,240.42 | $5,991.45 |
- 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
- $1,477.11 / $2,004.65 / $3,312.95
| Professional | | $1,477.11 | $2,004.65 | $3,312.95 |