- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,429.01 / $2,914.81 / $2,914.81
| Facility | | $2,429.01 | $2,914.81 | $2,914.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.41 / $1,554.57 / $1,651.73
| Professional | | $1,457.41 | $1,554.57 | $1,651.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,623.33 / $10,930.56 / $52,466.68
| Facility | | $2,623.33 | $10,930.56 | $52,466.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,331.85 / $2,623.33 / $119,998.80
| Professional | | $2,331.85 | $2,623.33 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,578.86 / $2,331.85 / $5,829.16
| Facility | | $1,578.86 | $2,331.85 | $5,829.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,366.27 / $9,366.27 / $9,366.27
| Professional | | $9,366.27 | $9,366.27 | $9,366.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $971.61 / $3,109.14
| Professional | | $816.15 | $971.61 | $3,109.14 |