- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $3,190.55
| Facility | | $960.00 | $1,728.00 | $3,190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,896.01 / $3,190.55 / $3,190.55
| Professional | | $1,896.01 | $3,190.55 | $3,190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,529.58 / $10,351.04 / $13,925.47
| Facility | | $8,529.58 | $10,351.04 | $13,925.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,624.25 / $2,225.00 / $2,625.50
| Professional | | $1,624.25 | $2,225.00 | $2,625.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.71 / $2,379.23 / $5,675.54
| Professional | | $1,900.71 | $2,379.23 | $5,675.54 |
- 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
- $1,605.42 / $1,984.10 / $3,435.33
| Professional | | $1,605.42 | $1,984.10 | $3,435.33 |