- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $530.00 / $2,784.38 / $7,450.63
| Facility | | $530.00 | $2,784.38 | $7,450.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.40 / $2,784.38 / $2,867.91
| Professional | | $1,473.40 | $2,784.38 | $2,867.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,626.77 / $2,784.38 / $2,784.38
| Facility | | $2,626.77 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Professional | | $2,784.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Facility | | $2,784.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.99 / $2,941.98 / $2,941.98
| Professional | | $1,470.99 | $2,941.98 | $2,941.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $138.05 / $495.68
| Professional | | $40.00 | $138.05 | $495.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,812.22
| Professional | | $2,784.38 | $2,784.38 | $2,812.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.00 / $530.00 / $2,784.38
| Professional | | $530.00 | $530.00 | $2,784.38 |