- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $3,589.33
| Facility | | $960.00 | $1,728.00 | $3,589.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,829.22 / $3,589.33 / $3,589.33
| Professional | | $1,829.22 | $3,589.33 | $3,589.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,985.60 / $2,720.00 / $3,209.60
| Professional | | $1,985.60 | $2,720.00 | $3,209.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,711.06 / $2,386.06 / $5,862.31
| Professional | | $1,711.06 | $2,386.06 | $5,862.31 |
- 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
- $1,482.20 / $2,075.08 / $3,038.73
| Professional | | $1,482.20 | $2,075.08 | $3,038.73 |