- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.08 / $1,579.41 / $1,895.30
| Facility | | $1,036.08 | $1,579.41 | $1,895.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.65 / $1,036.08 / $1,074.00
| Professional | | $947.65 | $1,036.08 | $1,074.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,705.77 / $7,107.36 / $34,115.32
| Facility | | $1,705.77 | $7,107.36 | $34,115.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.24 / $1,705.77 / $119,998.80
| Professional | | $1,516.24 | $1,705.77 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,026.60 / $1,516.24 / $3,790.25
| Facility | | $1,026.60 | $1,516.24 | $3,790.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,090.21 / $6,090.21 / $6,090.21
| Professional | | $6,090.21 | $6,090.21 | $6,090.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $631.77 / $2,021.65
| Professional | | $530.67 | $631.77 | $2,021.65 |