- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.00 / $1,831.00 / $2,825.00
| Facility | | $875.00 | $1,831.00 | $2,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,536.72 / $16,536.72 / $16,536.72
| Professional | | $16,536.72 | $16,536.72 | $16,536.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,451.53 / $10,451.53 / $10,451.53
| Facility | | $10,451.53 | $10,451.53 | $10,451.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,451.53 / $10,451.53 / $10,451.53
| Professional | | $10,451.53 | $10,451.53 | $10,451.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,804.31 / $9,856.34 / $10,896.43
| Facility | | $8,804.31 | $9,856.34 | $10,896.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.00 / $5,800.00 / $14,043.00
| Facility | | $1,185.00 | $5,800.00 | $14,043.00 |