- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,412.44
| Facility | | $960.00 | $1,728.00 | $2,412.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,269.21 / $1,367.27 / $2,412.44
| Professional | | $1,269.21 | $1,367.27 | $2,412.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,955.07 / $7,209.09 / $9,698.54
| Facility | | $5,955.07 | $7,209.09 | $9,698.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.14 / $1,718.00 / $2,202.48
| Professional | | $1,254.14 | $1,718.00 | $2,202.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.51 / $1,726.59 / $5,051.16
| Professional | | $908.51 | $1,726.59 | $5,051.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,404.00 / $4,852.00 / $9,624.00
| Facility | | $1,404.00 | $4,852.00 | $9,624.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.45 / $1,417.78 / $2,205.42
| Professional | | $992.45 | $1,417.78 | $2,205.42 |