- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $3,520.08
| Facility | | $960.00 | $1,728.00 | $3,520.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.71 / $3,520.08 / $3,520.08
| Professional | | $1,918.71 | $3,520.08 | $3,520.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,805.76 / $28,889.41 / $38,865.50
| Facility | | $23,805.76 | $28,889.41 | $38,865.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.00 / $2,001.93 / $3,470.89
| Professional | | $670.00 | $2,001.93 | $3,470.89 |
- 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
- $1,218.05 / $1,729.08 / $3,344.58
| Professional | | $1,218.05 | $1,729.08 | $3,344.58 |