- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,768.00 / $7,895.92
| Facility | | $960.00 | $1,768.00 | $7,895.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,575.88 / $3,392.88 / $5,848.83
| Professional | | $2,575.88 | $3,392.88 | $5,848.83 |
- 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
- $2,246.94 / $3,385.80 / $3,937.26
| Professional | | $2,246.94 | $3,385.80 | $3,937.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,575.31 / $3,343.16 / $10,077.48
| Professional | | $2,575.31 | $3,343.16 | $10,077.48 |
- 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
- $2,268.79 / $3,047.77 / $5,002.59
| Professional | | $2,268.79 | $3,047.77 | $5,002.59 |