- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,589.17 / $2,422.51 / $2,907.02
| Facility | | $1,589.17 | $2,422.51 | $2,907.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.51 / $1,589.17 / $1,647.31
| Professional | | $1,453.51 | $1,589.17 | $1,647.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,616.31 / $10,901.31 / $52,326.28
| Facility | | $2,616.31 | $10,901.31 | $52,326.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,325.61 / $2,616.31 / $119,998.80
| Professional | | $2,325.61 | $2,616.31 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,574.64 / $2,325.61 / $5,813.56
| Facility | | $1,574.64 | $2,325.61 | $5,813.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,341.20 / $9,341.20 / $9,341.20
| Professional | | $9,341.20 | $9,341.20 | $9,341.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.96 / $969.01 / $2,810.11
| Professional | | $813.96 | $969.01 | $2,810.11 |