- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $17,378.01
| Facility | | $3,890.45 | $3,890.45 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $3,890.45
| Professional | | $2,089.30 | $3,019.95 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $24,547.09 / $26,915.35
| Facility | | $4,466.84 | $24,547.09 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,238.72 / $3,715.35
| Professional | | $1,548.82 | $2,238.72 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Facility | | $8,709.64 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,890.45 / $7,244.36
| Professional | | $1,659.59 | $3,890.45 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $4,677.35
| Professional | | $3,890.45 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $6,309.57
| Facility | | $3,890.45 | $3,890.45 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,715.35 / $5,754.40
| Professional | | $2,570.40 | $3,715.35 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,890.45 / $6,025.60
| Professional | | $2,344.23 | $3,890.45 | $6,025.60 |