- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $3,932.10
| Facility | | $960.00 | $1,728.00 | $3,932.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.73 / $3,932.10 / $4,878.63
| Professional | | $2,209.73 | $3,932.10 | $4,878.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,404.27 / $19,907.34 / $26,781.76
| Facility | | $16,404.27 | $19,907.34 | $26,781.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,024.01 / $3,324.72 / $8,008.13
| Professional | | $2,024.01 | $3,324.72 | $8,008.13 |
- 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
- $1,814.86 / $2,782.78 / $4,513.89
| Professional | | $1,814.86 | $2,782.78 | $4,513.89 |