- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,111.21 / $3,218.31 / $3,861.97
| Facility | | $2,111.21 | $3,218.31 | $3,861.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,930.99 / $2,111.21 / $2,188.44
| Professional | | $1,930.99 | $2,111.21 | $2,188.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,475.78 / $14,482.41 / $69,515.56
| Facility | | $3,475.78 | $14,482.41 | $69,515.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,089.58 / $3,475.78 / $119,998.80
| Professional | | $3,089.58 | $3,475.78 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,091.90 / $3,089.58 / $7,723.29
| Facility | | $2,091.90 | $3,089.58 | $7,723.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,409.81 / $12,409.81 / $12,409.81
| Professional | | $12,409.81 | $12,409.81 | $12,409.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.34 / $1,287.33 / $3,733.24
| Professional | | $1,081.34 | $1,287.33 | $3,733.24 |