- 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
- $1,159.08 / $1,159.08 / $1,159.08
| Professional | | $1,159.08 | $1,159.08 | $1,159.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,159.08 / $1,622.71 / $1,657.48
| Facility | | $1,159.08 | $1,622.71 | $1,657.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,287.50 / $3,933.90 / $5,332.62
| Professional | | $3,287.50 | $3,933.90 | $5,332.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,159.08 / $1,622.71 / $1,657.48
| Facility | | $1,159.08 | $1,622.71 | $1,657.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,287.50 / $4,150.50 / $6,146.65
| Professional | | $3,287.50 | $4,150.50 | $6,146.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,045.72 / $8,045.72 / $8,045.72
| Facility | | $8,045.72 | $8,045.72 | $8,045.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.92 / $2,135.36 / $5,265.45
| Professional | | $2,100.92 | $2,135.36 | $5,265.45 |