- 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
- $1,036.45 / $2,033.60 / $2,745.36
| Professional | | $1,036.45 | $2,033.60 | $2,745.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.53 / $1,561.00 / $1,841.98
| Professional | | $1,139.53 | $1,561.00 | $1,841.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.72 / $1,368.64 / $3,200.63
| Professional | | $1,005.72 | $1,368.64 | $3,200.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $657.00 / $1,826.00 / $5,314.00
| Facility | | $657.00 | $1,826.00 | $5,314.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.17 / $1,152.45 / $1,758.75
| Professional | | $840.17 | $1,152.45 | $1,758.75 |