- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,179.94 / $2,615.92 / $2,615.92
| Facility | | $2,179.94 | $2,615.92 | $2,615.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,354.33 / $9,809.71 / $47,086.66
| Facility | | $2,354.33 | $9,809.71 | $47,086.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.73 / $2,354.33 / $119,998.80
| Professional | | $2,092.73 | $2,354.33 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,416.96 / $2,092.73 / $5,231.43
| Facility | | $1,416.96 | $2,092.73 | $5,231.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,405.84 / $8,405.84 / $8,405.84
| Professional | | $8,405.84 | $8,405.84 | $8,405.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $732.46 / $732.46 / $732.46
| Facility | | $732.46 | $732.46 | $732.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.32 / $584.90 / $1,696.21
| Professional | | $491.32 | $584.90 | $1,696.21 |