- 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
- $791.70 / $791.70 / $791.70
| Professional | | $791.70 | $791.70 | $791.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $791.70 / $1,108.38 / $1,132.13
| Facility | | $791.70 | $1,108.38 | $1,132.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $791.70 / $1,108.38 / $1,132.13
| Facility | | $791.70 | $1,108.38 | $1,132.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,377.39 / $3,875.52 / $5,940.81
| Professional | | $2,377.39 | $3,875.52 | $5,940.81 |