- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,245.63 / $1,898.83 / $2,278.59
| Facility | | $1,245.63 | $1,898.83 | $2,278.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.30 / $1,245.63 / $1,291.20
| Professional | | $1,139.30 | $1,245.63 | $1,291.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.73 / $8,544.70 / $41,014.62
| Facility | | $2,050.73 | $8,544.70 | $41,014.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.87 / $2,050.73 / $119,998.80
| Professional | | $1,822.87 | $2,050.73 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,234.24 / $1,822.87 / $4,556.80
| Facility | | $1,234.24 | $1,822.87 | $4,556.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,321.87 / $7,321.87 / $7,321.87
| Professional | | $7,321.87 | $7,321.87 | $7,321.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.01 / $759.53 / $2,202.64
| Professional | | $638.01 | $759.53 | $2,202.64 |