- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,285.00 / $10,900.00 / $17,695.00
| Facility | | $9,285.00 | $10,900.00 | $17,695.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.38 / $2,673.02 / $2,673.02
| Professional | | $1,657.38 | $2,673.02 | $2,673.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,215.37 / $2,673.02 / $3,742.23
| Facility | | $2,215.37 | $2,673.02 | $3,742.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,381.00 / $9,156.74 / $12,442.95
| Professional | | $6,381.00 | $9,156.74 | $12,442.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,215.37 / $2,673.02 / $3,742.23
| Facility | | $2,215.37 | $2,673.02 | $3,742.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,381.00 / $9,571.50 / $14,580.59
| Professional | | $6,381.00 | $9,571.50 | $14,580.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,482.50 / $8,689.93 / $12,672.53
| Professional | | $5,482.50 | $8,689.93 | $12,672.53 |