- 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
- $1,033.20 / $2,066.06 / $2,066.06
| Professional | | $1,033.20 | $2,066.06 | $2,066.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.83 / $1,408.00 / $1,661.44
| Professional | | $1,027.83 | $1,408.00 | $1,661.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.30 / $1,287.28 / $3,277.90
| Professional | | $985.30 | $1,287.28 | $3,277.90 |
- 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
- $809.59 / $1,107.34 / $1,685.03
| Professional | | $809.59 | $1,107.34 | $1,685.03 |