- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $5,788.60
| Facility | | $960.00 | $1,728.00 | $5,788.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,180.29 / $5,788.60 / $5,788.60
| Professional | | $3,180.29 | $5,788.60 | $5,788.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,526.46 / $3,460.91 / $4,083.87
| Professional | | $2,526.46 | $3,460.91 | $4,083.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,707.97 / $4,735.30 / $12,177.19
| Professional | | $2,707.97 | $4,735.30 | $12,177.19 |
- 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
- $2,583.87 / $3,506.68 / $5,654.05
| Professional | | $2,583.87 | $3,506.68 | $5,654.05 |