- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.00 / $3,742.00 / $18,600.00
| Facility | | $1,346.00 | $3,742.00 | $18,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.30 / $3,424.40 / $3,472.09
| Professional | | $2,721.30 | $3,424.40 | $3,472.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.00 / $900.00 / $900.00
| Facility | | $900.00 | $900.00 | $900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,293.78 / $4,153.54 / $5,359.93
| Professional | | $3,293.78 | $4,153.54 | $5,359.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,188.84 / $4,401.97 / $18,958.34
| Facility | | $3,188.84 | $4,401.97 | $18,958.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,889.52 / $3,663.49 / $27,142.49
| Professional | | $2,889.52 | $3,663.49 | $27,142.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,917.00 / $13,550.00 / $20,812.48
| Facility | | $3,917.00 | $13,550.00 | $20,812.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.44 / $3,418.05 / $4,819.45
| Professional | | $2,734.44 | $3,418.05 | $4,819.45 |