- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,250.00
| Facility | | $960.00 | $1,728.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.93 / $1,204.52 / $1,964.87
| Professional | | $1,072.93 | $1,204.52 | $1,964.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,537.39 / $11,574.08 / $15,570.84
| Facility | | $9,537.39 | $11,574.08 | $15,570.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.70 / $2,250.28 / $2,655.33
| Professional | | $1,642.70 | $2,250.28 | $2,655.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.56 / $1,422.25 / $4,179.96
| Professional | | $1,046.56 | $1,422.25 | $4,179.96 |
- 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
- $942.64 / $1,212.24 / $2,060.81
| Professional | | $942.64 | $1,212.24 | $2,060.81 |