- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.00 / $2,854.11 / $4,050.00
| Facility | | $900.00 | $2,854.11 | $4,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,854.11 / $3,371.27 / $3,677.75
| Professional | | $2,854.11 | $3,371.27 | $3,677.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,832.66 / $3,426.56 / $4,667.14
| Professional | | $2,832.66 | $3,426.56 | $4,667.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.00 / $1,309.00 / $7,168.00
| Facility | | $385.00 | $1,309.00 | $7,168.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,276.80 / $3,728.00 / $5,254.73
| Professional | | $2,276.80 | $3,728.00 | $5,254.73 |