- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,058.37 / $3,137.76 / $3,765.31
| Facility | | $2,058.37 | $3,137.76 | $3,765.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,882.66 / $2,058.37 / $2,133.67
| Professional | | $1,882.66 | $2,058.37 | $2,133.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.78 / $14,119.93 / $67,775.67
| Facility | | $3,388.78 | $14,119.93 | $67,775.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,012.25 / $3,388.78 / $119,998.80
| Professional | | $3,012.25 | $3,388.78 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,039.55 / $3,012.25 / $7,530.02
| Facility | | $2,039.55 | $3,012.25 | $7,530.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,099.21 / $12,099.21 / $12,099.21
| Professional | | $12,099.21 | $12,099.21 | $12,099.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,255.10 / $3,639.80
| Professional | | $1,054.29 | $1,255.10 | $3,639.80 |