- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $5,775.64
| Facility | | $960.00 | $1,728.00 | $5,775.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,535.92 / $3,351.26 / $5,775.64
| Professional | | $2,535.92 | $3,351.26 | $5,775.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,718.36 / $8,153.05 / $10,968.47
| Facility | | $6,718.36 | $8,153.05 | $10,968.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.03 / $3,202.10 / $3,731.90
| Professional | | $2,125.03 | $3,202.10 | $3,731.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.54 / $3,274.07 / $9,970.81
| Professional | | $2,480.54 | $3,274.07 | $9,970.81 |
- 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
- $2,195.89 / $2,917.83 / $4,812.91
| Professional | | $2,195.89 | $2,917.83 | $4,812.91 |