- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $4,024.94
| Facility | | $960.00 | $1,728.00 | $4,024.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.42 / $4,024.94 / $4,992.14
| Professional | | $2,264.42 | $4,024.94 | $4,992.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,701.36 / $19,054.33 / $25,634.18
| Facility | | $15,701.36 | $19,054.33 | $25,634.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,427.25 / $3,325.00 / $3,923.50
| Professional | | $2,427.25 | $3,325.00 | $3,923.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,263.67 / $3,226.42 / $8,190.05
| Professional | | $2,263.67 | $3,226.42 | $8,190.05 |
- 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
- $1,808.09 / $2,532.77 / $3,888.62
| Professional | | $1,808.09 | $2,532.77 | $3,888.62 |