- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,438.50 / $2,250.00
| Facility | | $960.00 | $1,438.50 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.02 / $1,438.50 / $1,438.50
| Professional | | $911.02 | $1,438.50 | $1,438.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.85 / $1,345.00 / $1,587.10
| Professional | | $981.85 | $1,345.00 | $1,587.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.65 / $1,179.46 / $3,236.07
| Professional | | $901.65 | $1,179.46 | $3,236.07 |
- 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
- $822.57 / $1,041.92 / $1,671.17
| Professional | | $822.57 | $1,041.92 | $1,671.17 |