- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,916.50
| Facility | | $960.00 | $1,728.00 | $2,916.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,641.93 / $2,916.50 / $3,617.06
| Professional | | $1,641.93 | $2,916.50 | $3,617.06 |
- 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
- $1,746.16 / $2,392.00 / $2,822.56
| Professional | | $1,746.16 | $2,392.00 | $2,822.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,641.77 / $2,386.21 / $5,934.17
| Professional | | $1,641.77 | $2,386.21 | $5,934.17 |
- 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
- $1,346.33 / $1,858.00 / $2,818.31
| Professional | | $1,346.33 | $1,858.00 | $2,818.31 |