- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $8,128.31 / $16,218.10
| Facility | | $3,162.28 | $8,128.31 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,905.46 / $2,238.72
| Professional | | $1,445.44 | $1,905.46 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $9,549.93 / $10,964.78
| Facility | | $7,585.78 | $9,549.93 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,905.46 / $5,623.41
| Facility | | $912.01 | $1,905.46 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $16,218.10
| Professional | | $1,905.46 | $2,454.71 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,778.28 / $5,623.41
| Facility | | $912.01 | $1,778.28 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $3,235.94
| Professional | | $1,905.46 | $2,454.71 | $3,235.94 |