- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $803.00 / $1,411.50 / $2,812.00
| Facility | | $803.00 | $1,411.50 | $2,812.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.21 / $1,516.56 / $1,517.13
| Professional | | $955.21 | $1,516.56 | $1,517.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.54 / $1,509.54 / $1,509.54
| Professional | | $1,140.54 | $1,509.54 | $1,509.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.00 / $1,707.67 / $2,129.55
| Professional | | $1,230.00 | $1,707.67 | $2,129.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.00 / $838.00 / $1,574.00
| Facility | | $330.00 | $838.00 | $1,574.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.42 / $1,218.02 / $2,175.96
| Professional | | $974.42 | $1,218.02 | $2,175.96 |