- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,678.00 / $2,250.00
| Facility | | $960.00 | $1,678.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $698.93 / $1,100.47 / $1,100.47
| Professional | | $698.93 | $1,100.47 | $1,100.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.82 / $1,618.34 / $1,909.64
| Professional | | $1,148.82 | $1,618.34 | $1,909.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.04 / $1,077.48 / $2,480.37
| Professional | | $685.04 | $1,077.48 | $2,480.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.00 / $3,129.00 / $5,251.00
| Facility | | $950.00 | $3,129.00 | $5,251.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.58 / $856.77 / $1,303.56
| Professional | | $642.58 | $856.77 | $1,303.56 |