- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $4,400.27
| Facility | | $960.00 | $1,728.00 | $4,400.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,119.01 / $2,490.92 / $4,400.27
| Professional | | $2,119.01 | $2,490.92 | $4,400.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,862.11 / $15,570.61 / $20,947.46
| Facility | | $12,862.11 | $15,570.61 | $20,947.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,302.42 / $3,154.00 / $4,043.43
| Professional | | $2,302.42 | $3,154.00 | $4,043.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,313.14 / $3,169.77 / $8,317.61
| Professional | | $2,313.14 | $3,169.77 | $8,317.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.00 / $6,323.00 / $12,422.00
| Facility | | $1,500.00 | $6,323.00 | $12,422.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,095.52 / $2,667.17 / $4,457.68
| Professional | | $2,095.52 | $2,667.17 | $4,457.68 |