- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.69 / $2,773.91 / $3,328.69
| Facility | | $1,819.69 | $2,773.91 | $3,328.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.35 / $1,819.69 / $1,819.69
| Professional | | $1,664.35 | $1,819.69 | $1,819.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,975.05 / $12,482.61 / $59,916.52
| Facility | | $1,975.05 | $12,482.61 | $59,916.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,912.75 / $2,995.83 / $119,998.80
| Professional | | $1,912.75 | $2,995.83 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,803.04 / $2,662.96 / $6,656.81
| Facility | | $1,803.04 | $2,662.96 | $6,656.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $3,187.33 / $10,696.21
| Professional | | $2,549.86 | $3,187.33 | $10,696.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $998.61 / $2,995.83
| Professional | | $932.03 | $998.61 | $2,995.83 |