- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,435.42
| Facility | | $960.00 | $1,728.00 | $2,435.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,566.40 / $2,435.42 / $2,435.42
| Professional | | $1,566.40 | $2,435.42 | $2,435.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,682.65 / $2,305.00 / $2,719.90
| Professional | | $1,682.65 | $2,305.00 | $2,719.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,451.81 / $2,021.50 / $4,975.87
| Professional | | $1,451.81 | $2,021.50 | $4,975.87 |
- 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
- $1,258.08 / $1,623.03 / $2,578.39
| Professional | | $1,258.08 | $1,623.03 | $2,578.39 |