- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $3,620.75
| Facility | | $960.00 | $1,728.00 | $3,620.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.36 / $2,228.61 / $3,620.75
| Professional | | $2,004.36 | $2,228.61 | $3,620.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,484.66 / $21,218.47 / $28,545.63
| Facility | | $17,484.66 | $21,218.47 | $28,545.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,110.42 / $2,891.00 / $3,706.26
| Professional | | $2,110.42 | $2,891.00 | $3,706.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,970.70 / $3,013.36 / $7,762.95
| Professional | | $1,970.70 | $3,013.36 | $7,762.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $5,201.00
| Facility | | $650.00 | $1,754.00 | $5,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,827.46 / $2,231.33 / $3,920.19
| Professional | | $1,827.46 | $2,231.33 | $3,920.19 |