- 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
- $1,771.40 / $2,661.53 / $2,661.53
| Professional | | $1,771.40 | $2,661.53 | $2,661.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,771.40 / $2,661.53 / $3,726.14
| Facility | | $1,771.40 | $2,661.53 | $3,726.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,595.00 / $7,549.50 / $10,717.14
| Professional | | $3,595.00 | $7,549.50 | $10,717.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,262.30 / $2,661.53 / $3,726.14
| Facility | | $2,262.30 | $2,661.53 | $3,726.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.99 / $7,507.50 / $10,228.50
| Professional | | $1,394.99 | $7,507.50 | $10,228.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,676.10 / $9,568.34 / $12,028.76
| Professional | | $4,676.10 | $9,568.34 | $12,028.76 |