- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,910.85 / $7,310.00 / $10,965.00
| Facility | | $3,910.85 | $7,310.00 | $10,965.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,960.55 / $2,960.55 / $3,552.66
| Professional | | $2,960.55 | $2,960.55 | $3,552.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,436.66 / $9,606.54 / $15,183.46
| Facility | | $2,436.66 | $9,606.54 | $15,183.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.21 / $2,436.66 / $19,375.16
| Professional | | $1,675.21 | $2,436.66 | $19,375.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,256.61 / $3,655.00 / $4,233.59
| Facility | | $3,256.61 | $3,655.00 | $4,233.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,045.83 / $3,045.83 / $3,045.83
| Professional | | $3,045.83 | $3,045.83 | $3,045.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,045.83 / $3,045.83 / $3,045.83
| Professional | | $3,045.83 | $3,045.83 | $3,045.83 |