- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,570.88 / $16,218.10
| Facility | | $3,388.44 | $4,570.88 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,691.53 / $4,073.80
| Professional | | $1,905.46 | $2,691.53 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Professional | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Facility | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $24,547.09
| Facility | | $2,089.30 | $2,089.30 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,235.94 / $3,235.94
| Facility | | $1,348.96 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,584.89 / $4,466.84
| Professional | | $1,348.96 | $1,584.89 | $4,466.84 |