- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $4,466.84
| Facility | | $3,019.95 | $3,019.95 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,019.95 / $3,467.37
| Professional | | $1,862.09 | $3,019.95 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $11,220.18 / $13,489.63
| Facility | | $3,630.78 | $11,220.18 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $1,445.44 / $3,715.35
| Professional | | $229.09 | $1,445.44 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $3,090.30 / $4,073.80
| Professional | | $512.86 | $3,090.30 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $588.84 / $3,715.35
| Facility | | $295.12 | $588.84 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,630.78 / $6,456.54
| Professional | | $1,445.44 | $3,630.78 | $6,456.54 |