- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $5,051.03
| Facility | | $960.00 | $1,728.00 | $5,051.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,837.14 / $5,051.03 / $6,265.43
| Professional | | $2,837.14 | $5,051.03 | $6,265.43 |
- 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
- $2,549.89 / $3,493.00 / $4,121.74
| Professional | | $2,549.89 | $3,493.00 | $4,121.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.67 / $3,929.31 / $10,191.45
| Professional | | $2,818.67 | $3,929.31 | $10,191.45 |
- 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
- $2,294.62 / $3,131.95 / $4,861.49
| Professional | | $2,294.62 | $3,131.95 | $4,861.49 |