- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,477.71
| Facility | | $960.00 | $1,728.00 | $2,477.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.89 / $1,407.08 / $2,477.71
| Professional | | $1,297.89 | $1,407.08 | $2,477.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,931.14 / $7,197.72 / $9,683.24
| Facility | | $5,931.14 | $7,197.72 | $9,683.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,220.40 / $3,172.00 / $3,742.96
| Professional | | $2,220.40 | $3,172.00 | $3,742.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.45 / $1,943.19 / $5,412.86
| Professional | | $1,317.45 | $1,943.19 | $5,412.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,074.00 / $3,816.00 / $7,227.00
| Facility | | $1,074.00 | $3,816.00 | $7,227.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.13 / $1,522.97 / $2,594.42
| Professional | | $1,216.13 | $1,522.97 | $2,594.42 |