- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,285.00 / $10,900.00 / $14,552.94
| Facility | | $9,285.00 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.02 / $956.02 / $956.02
| Professional | | $956.02 | $956.02 | $956.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $956.02 / $1,338.43 / $1,367.11
| Facility | | $956.02 | $1,338.43 | $1,367.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.50 / $2,479.50 / $11,038.00
| Professional | | $2,137.50 | $2,479.50 | $11,038.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $956.02 / $1,338.43 / $1,367.11
| Facility | | $956.02 | $1,338.43 | $1,367.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,138.75 / $8,278.50 / $13,135.22
| Professional | | $2,138.75 | $8,278.50 | $13,135.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,928.91 / $7,483.41 / $11,483.35
| Professional | | $2,928.91 | $7,483.41 | $11,483.35 |