- 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
- $2,177.67 / $2,177.67 / $2,177.67
| Professional | | $2,177.67 | $2,177.67 | $2,177.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,177.67 / $3,048.74 / $3,114.07
| Facility | | $2,177.67 | $3,048.74 | $3,114.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,932.50 / $7,588.26 / $8,254.00
| Professional | | $6,932.50 | $7,588.26 | $8,254.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,177.67 / $3,048.74 / $3,114.07
| Facility | | $2,177.67 | $3,048.74 | $3,114.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,916.00 / $7,588.26 / $9,822.26
| Professional | | $5,916.00 | $7,588.26 | $9,822.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,574.92 / $3,695.60 / $8,499.87
| Professional | | $3,574.92 | $3,695.60 | $8,499.87 |