- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $4,086.56
| Facility | | $960.00 | $1,728.00 | $4,086.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.41 / $4,086.56 / $5,070.99
| Professional | | $2,298.41 | $4,086.56 | $5,070.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,404.27 / $19,907.34 / $26,781.76
| Facility | | $16,404.27 | $19,907.34 | $26,781.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,533.10 / $3,470.00 / $4,094.60
| Professional | | $2,533.10 | $3,470.00 | $4,094.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,292.94 / $3,262.52 / $8,384.36
| Professional | | $2,292.94 | $3,262.52 | $8,384.36 |
- 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
- $1,760.56 / $2,509.31 / $3,948.68
| Professional | | $1,760.56 | $2,509.31 | $3,948.68 |