- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,305.13
| Facility | | $960.00 | $1,728.00 | $2,305.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.73 / $2,305.13 / $2,305.13
| Professional | | $1,307.73 | $2,305.13 | $2,305.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,644.41 / $5,636.21 / $7,582.51
| Facility | | $4,644.41 | $5,636.21 | $7,582.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,421.31 / $1,947.00 / $2,297.46
| Professional | | $1,421.31 | $1,947.00 | $2,297.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.31 / $1,710.25 / $5,384.56
| Professional | | $1,314.31 | $1,710.25 | $5,384.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,124.00 / $3,384.00 / $5,251.00
| Facility | | $1,124.00 | $3,384.00 | $5,251.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.02 / $1,485.45 / $2,275.50
| Professional | | $1,087.02 | $1,485.45 | $2,275.50 |