- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $4,045.04
| Facility | | $960.00 | $1,728.00 | $4,045.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,780.03 / $2,347.96 / $4,045.04
| Professional | | $1,780.03 | $2,347.96 | $4,045.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,353.71 / $4,069.89 / $5,475.31
| Facility | | $3,353.71 | $4,069.89 | $5,475.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,580.45 / $2,381.50 / $2,723.00
| Professional | | $1,580.45 | $2,381.50 | $2,723.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.72 / $2,314.92 / $6,984.38
| Professional | | $1,782.72 | $2,314.92 | $6,984.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $4,083.00
| Facility | | $650.00 | $1,754.00 | $4,083.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.63 / $2,105.83 / $3,457.46
| Professional | | $1,572.63 | $2,105.83 | $3,457.46 |