- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $4,105.80
| Facility | | $960.00 | $1,728.00 | $4,105.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.86 / $4,105.80 / $5,092.35
| Professional | | $2,272.86 | $4,105.80 | $5,092.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,701.36 / $19,054.33 / $25,634.18
| Facility | | $15,701.36 | $19,054.33 | $25,634.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,409.73 / $3,301.00 / $3,895.18
| Professional | | $2,409.73 | $3,301.00 | $3,895.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,309.21 / $3,342.46 / $8,792.66
| Professional | | $2,309.21 | $3,342.46 | $8,792.66 |
- 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
- $1,876.49 / $2,601.31 / $3,968.52
| Professional | | $1,876.49 | $2,601.31 | $3,968.52 |