- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,590.71 / $3,949.27 / $4,739.13
| Facility | | $2,590.71 | $3,949.27 | $4,739.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,369.57 / $2,590.71 / $2,685.51
| Professional | | $2,369.57 | $2,590.71 | $2,685.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.22 / $17,771.74 / $85,304.34
| Facility | | $4,265.22 | $17,771.74 | $85,304.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,791.30 / $4,265.22 / $119,998.80
| Professional | | $3,791.30 | $4,265.22 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,567.03 / $3,791.30 / $9,477.45
| Facility | | $2,567.03 | $3,791.30 | $9,477.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,228.40 / $15,228.40 / $15,228.40
| Professional | | $15,228.40 | $15,228.40 | $15,228.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,579.71 / $4,581.16
| Professional | | $1,326.96 | $1,579.71 | $4,581.16 |