- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,639.00
| Facility | | $960.00 | $1,728.00 | $2,639.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,888.54 / $3,071.26 / $3,071.26
| Professional | | $1,888.54 | $3,071.26 | $3,071.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,996.56 / $4,838.16 / $6,508.87
| Facility | | $3,996.56 | $4,838.16 | $6,508.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.17 / $2,829.00 / $3,338.22
| Professional | | $2,065.17 | $2,829.00 | $3,338.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,002.03 / $2,477.73 / $7,709.63
| Professional | | $2,002.03 | $2,477.73 | $7,709.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,074.00 / $3,816.00 / $7,227.00
| Facility | | $1,074.00 | $3,816.00 | $7,227.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,647.04 / $2,109.82 / $3,447.80
| Professional | | $1,647.04 | $2,109.82 | $3,447.80 |