- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,250.00
| Facility | | $960.00 | $1,728.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.05 / $2,170.10 / $2,170.10
| Professional | | $1,106.05 | $2,170.10 | $2,170.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.33 / $1,621.00 / $1,912.78
| Professional | | $1,183.33 | $1,621.00 | $1,912.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.48 / $1,421.60 / $3,545.67
| Professional | | $1,034.48 | $1,421.60 | $3,545.67 |
- 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
- $896.74 / $1,159.78 / $1,836.86
| Professional | | $896.74 | $1,159.78 | $1,836.86 |