- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $6,141.08
| Facility | | $960.00 | $1,728.00 | $6,141.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,701.20 / $3,482.90 / $6,141.08
| Professional | | $2,701.20 | $3,482.90 | $6,141.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,496.20 / $10,310.54 / $13,870.99
| Facility | | $8,496.20 | $10,310.54 | $13,870.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.04 / $3,301.57 / $3,961.75
| Professional | | $2,191.04 | $3,301.57 | $3,961.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,322.79 / $3,365.16 / $10,653.46
| Professional | | $2,322.79 | $3,365.16 | $10,653.46 |
- 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
- $2,242.82 / $3,022.56 / $5,126.45
| Professional | | $2,242.82 | $3,022.56 | $5,126.45 |