- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $6,295.34
| Facility | | $960.00 | $1,728.00 | $6,295.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,602.29 / $3,520.05 / $6,295.34
| Professional | | $2,602.29 | $3,520.05 | $6,295.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,974.38 / $8,463.73 / $11,386.43
| Facility | | $6,974.38 | $8,463.73 | $11,386.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,976.21 / $4,278.82 / $4,890.08
| Professional | | $2,976.21 | $4,278.82 | $4,890.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,657.72 / $3,895.74 / $10,955.78
| Professional | | $2,657.72 | $3,895.74 | $10,955.78 |
- 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
- $2,308.56 / $3,058.47 / $5,664.14
| Professional | | $2,308.56 | $3,058.47 | $5,664.14 |