- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.00 / $1,714.56 / $2,470.00
| Facility | | $950.00 | $1,714.56 | $2,470.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.00 / $1,852.50 / $1,852.50
| Professional | | $665.00 | $1,852.50 | $1,852.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.00 / $1,976.00 / $3,705.00
| Facility | | $741.00 | $1,976.00 | $3,705.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,143.04 / $1,852.50 / $2,037.75
| Facility | | $1,143.04 | $1,852.50 | $2,037.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.00 / $950.00 / $1,140.00
| Professional | | $950.00 | $950.00 | $1,140.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $1,852.50
| Professional | | $30.00 | $30.00 | $1,852.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,425.00 / $1,900.00 / $3,420.00
| Facility | | $1,425.00 | $1,900.00 | $3,420.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.87 / $1,419.87 / $1,510.83
| Professional | | $1,419.87 | $1,419.87 | $1,510.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.00 / $399.00 / $1,092.50
| Professional | | $399.00 | $399.00 | $1,092.50 |