- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.94 / $3,297.53 / $3,297.53
| Facility | | $2,747.94 | $3,297.53 | $3,297.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.76 / $1,758.68 / $1,868.60
| Professional | | $1,648.76 | $1,758.68 | $1,868.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,967.77 / $12,365.72 / $59,355.46
| Facility | | $2,967.77 | $12,365.72 | $59,355.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,638.02 / $2,967.77 / $119,998.80
| Professional | | $2,638.02 | $2,967.77 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.16 / $2,638.02 / $6,594.51
| Facility | | $1,786.16 | $2,638.02 | $6,594.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,596.05 / $10,596.05 / $10,596.05
| Professional | | $10,596.05 | $10,596.05 | $10,596.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $923.31 / $923.31 / $923.31
| Facility | | $923.31 | $923.31 | $923.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.31 / $1,099.18 / $3,187.61
| Professional | | $923.31 | $1,099.18 | $3,187.61 |