- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $7,507.30
| Facility | | $960.00 | $1,728.00 | $7,507.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,365.89 / $4,358.66 / $7,507.30
| Professional | | $3,365.89 | $4,358.66 | $7,507.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,428.03 / $6,587.17 / $8,861.85
| Facility | | $5,428.03 | $6,587.17 | $8,861.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,694.28 / $4,059.87 / $4,881.07
| Professional | | $2,694.28 | $4,059.87 | $4,881.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,411.03 / $4,579.89 / $7,402.47
| Professional | | $3,411.03 | $4,579.89 | $7,402.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $4,083.00
| Facility | | $650.00 | $1,754.00 | $4,083.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,926.88 / $4,081.89 / $6,532.70
| Professional | | $2,926.88 | $4,081.89 | $6,532.70 |