- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $3,117.58
| Facility | | $960.00 | $1,728.00 | $3,117.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,595.21 / $3,117.58 / $3,117.58
| Professional | | $1,595.21 | $3,117.58 | $3,117.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.07 / $2,359.00 / $2,783.62
| Professional | | $1,722.07 | $2,359.00 | $2,783.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.10 / $2,069.52 / $5,117.92
| Professional | | $1,493.10 | $2,069.52 | $5,117.92 |
- 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
- $1,295.44 / $1,634.06 / $2,652.41
| Professional | | $1,295.44 | $1,634.06 | $2,652.41 |