- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $800.00 / $1,399.00 / $2,587.14
| Facility | | $800.00 | $1,399.00 | $2,587.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.88 / $1,506.43 / $2,587.14
| Professional | | $1,139.88 | $1,506.43 | $2,587.14 |
- 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
- $1,265.53 / $1,906.96 / $2,557.06
| Professional | | $1,265.53 | $1,906.96 | $2,557.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.10 / $1,636.85 / $4,452.51
| Professional | | $1,151.10 | $1,636.85 | $4,452.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,196.00 / $4,121.00 / $17,103.00
| Facility | | $1,196.00 | $4,121.00 | $17,103.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.07 / $1,312.03 / $2,152.67
| Professional | | $1,009.07 | $1,312.03 | $2,152.67 |