- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,984.99 / $14,984.99 / $14,984.99
| Facility | | $14,984.99 | $14,984.99 | $14,984.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,866.02 / $3,873.00 / $3,873.00
| Professional | | $2,866.02 | $3,873.00 | $3,873.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,098.40 / $3,098.40 / $3,934.97
| Professional | | $3,098.40 | $3,098.40 | $3,934.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.69 / $2,546.96 / $9,519.23
| Professional | | $2,052.69 | $2,546.96 | $9,519.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,873.00 / $4,647.60 / $5,809.50
| Professional | | $3,873.00 | $4,647.60 | $5,809.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,626.66 / $1,626.66 / $1,626.66
| Facility | | $1,626.66 | $1,626.66 | $1,626.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $1,891.33 / $3,419.42
| Professional | | $1,626.66 | $1,891.33 | $3,419.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,936.50 / $3,079.04 / $3,079.04
| Professional | | $1,936.50 | $3,079.04 | $3,079.04 |