- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,355.58
| Facility | | $960.00 | $1,728.00 | $2,355.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.58 / $2,355.58 / $3,180.03
| Professional | | $1,157.58 | $2,355.58 | $3,180.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.05 / $1,585.00 / $1,870.30
| Professional | | $1,157.05 | $1,585.00 | $1,870.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.41 / $1,390.29 / $3,703.04
| Professional | | $1,080.41 | $1,390.29 | $3,703.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $657.00 / $1,835.00 / $6,546.00
| Facility | | $657.00 | $1,835.00 | $6,546.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $939.21 / $1,222.26 / $1,935.28
| Professional | | $939.21 | $1,222.26 | $1,935.28 |