- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $6,165.95 / $16,218.10
| Facility | | $3,019.95 | $6,165.95 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,019.95 / $5,248.07
| Professional | | $2,398.83 | $3,019.95 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,786.30 / $16,595.87
| Facility | | $3,630.78 | $4,786.30 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,778.28 / $5,888.44
| Professional | | $1,445.44 | $1,778.28 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $6,918.31 / $15,848.93
| Facility | | $2,344.23 | $6,918.31 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,168.69 / $8,709.64
| Professional | | $1,698.24 | $4,168.69 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,630.78 / $4,365.16
| Facility | | $2,137.96 | $3,630.78 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $4,365.16
| Professional | | $1,513.56 | $2,137.96 | $4,365.16 |