- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,678.11
| Facility | | $960.00 | $1,728.00 | $2,678.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,504.70 / $2,678.11 / $3,323.77
| Professional | | $1,504.70 | $2,678.11 | $3,323.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,455.92 / $16,329.40 / $21,968.27
| Facility | | $13,455.92 | $16,329.40 | $21,968.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.60 / $1,863.83 / $2,199.32
| Professional | | $1,360.60 | $1,863.83 | $2,199.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,501.82 / $2,695.37 / $6,627.17
| Professional | | $1,501.82 | $2,695.37 | $6,627.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $5,201.00
| Facility | | $650.00 | $1,754.00 | $5,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.52 / $1,897.52 / $2,640.03
| Professional | | $1,237.52 | $1,897.52 | $2,640.03 |