- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,522.08
| Facility | | $960.00 | $1,728.00 | $2,522.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.48 / $1,492.74 / $2,522.08
| Professional | | $1,345.48 | $1,492.74 | $2,522.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,945.68 / $7,197.72 / $9,683.24
| Facility | | $5,945.68 | $7,197.72 | $9,683.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.70 / $2,090.00 / $2,610.86
| Professional | | $1,525.70 | $2,090.00 | $2,610.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.73 / $1,821.18 / $5,352.30
| Professional | | $1,342.73 | $1,821.18 | $5,352.30 |
- 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
- $1,243.20 / $1,556.45 / $2,754.92
| Professional | | $1,243.20 | $1,556.45 | $2,754.92 |