- 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
- $1,687.61 / $1,687.61 / $1,687.61
| Professional | | $1,687.61 | $1,687.61 | $1,687.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,687.61 / $1,922.34 / $2,413.28
| Facility | | $1,687.61 | $1,922.34 | $2,413.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,400.00 / $6,042.00 / $8,058.00
| Professional | | $5,400.00 | $6,042.00 | $8,058.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,687.61 / $1,922.34 / $2,413.28
| Facility | | $1,687.61 | $1,922.34 | $2,413.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.81 / $6,043.50 / $9,589.02
| Professional | | $2,306.81 | $6,043.50 | $9,589.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,709.42 / $5,564.13 / $8,678.87
| Professional | | $3,709.42 | $5,564.13 | $8,678.87 |