- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.00 / $1,728.00 / $2,377.00
| Facility | | $1,040.00 | $1,728.00 | $2,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.57 / $2,162.90 / $2,162.90
| Professional | | $1,102.57 | $2,162.90 | $2,162.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.17 / $1,629.00 / $1,922.22
| Professional | | $1,189.17 | $1,629.00 | $1,922.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.71 / $1,429.22 / $3,545.34
| Professional | | $1,030.71 | $1,429.22 | $3,545.34 |
- 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
- $893.76 / $1,189.81 / $1,830.71
| Professional | | $893.76 | $1,189.81 | $1,830.71 |