- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,285.00 / $13,413.92 / $20,143.00
| Facility | | $9,285.00 | $13,413.92 | $20,143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,336.07 / $2,336.07 / $2,336.07
| Professional | | $2,336.07 | $2,336.07 | $2,336.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,340.58 / $3,340.58 / $3,340.58
| Facility | | $3,340.58 | $3,340.58 | $3,340.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,898.55 / $7,341.30 / $9,951.54
| Professional | | $4,898.55 | $7,341.30 | $9,951.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,340.58 / $3,340.58 / $3,340.58
| Facility | | $3,340.58 | $3,340.58 | $3,340.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,898.55 / $8,308.50 / $13,168.46
| Professional | | $4,898.55 | $8,308.50 | $13,168.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,410.65 / $5,020.88 / $15,204.03
| Professional | | $2,410.65 | $5,020.88 | $15,204.03 |