- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,941.10
| Facility | | $960.00 | $1,728.00 | $2,941.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,526.48 / $2,941.10 / $3,647.49
| Professional | | $1,526.48 | $2,941.10 | $3,647.49 |
- 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
- $2,242.57 / $3,072.02 / $3,624.98
| Professional | | $2,242.57 | $3,072.02 | $3,624.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,655.86 / $2,307.44 / $5,975.22
| Professional | | $1,655.86 | $2,307.44 | $5,975.22 |
- 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
- $1,347.81 / $1,701.25 / $2,738.08
| Professional | | $1,347.81 | $1,701.25 | $2,738.08 |