- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,736.00 / $6,907.00 / $9,160.00
| Facility | | $4,736.00 | $6,907.00 | $9,160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.15 / $1,277.64 / $3,238.03
| Professional | | $1,120.15 | $1,277.64 | $3,238.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,985.46 / $10,985.46 / $10,985.46
| Facility | | $10,985.46 | $10,985.46 | $10,985.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.23 / $1,304.20 / $2,322.17
| Professional | | $1,129.23 | $1,304.20 | $2,322.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.00 / $2,783.00 / $2,783.00
| Facility | | $2,783.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.58 / $1,400.89 / $2,921.61
| Professional | | $1,080.58 | $1,400.89 | $2,921.61 |