- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.48 / $2,657.75 / $3,189.30
| Facility | | $1,743.48 | $2,657.75 | $3,189.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,594.65 / $1,743.48 / $1,807.27
| Professional | | $1,594.65 | $1,743.48 | $1,807.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,870.37 / $11,959.88 / $57,407.40
| Facility | | $2,870.37 | $11,959.88 | $57,407.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,551.44 / $2,870.37 / $119,998.80
| Professional | | $2,551.44 | $2,870.37 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,727.54 / $2,551.44 / $6,378.07
| Facility | | $1,727.54 | $2,551.44 | $6,378.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,248.28 / $10,248.28 / $10,248.28
| Professional | | $10,248.28 | $10,248.28 | $10,248.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $893.00 / $893.00 / $893.00
| Facility | | $893.00 | $893.00 | $893.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.00 / $1,063.09 / $3,401.92
| Professional | | $893.00 | $1,063.09 | $3,401.92 |