- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,007.82 / $3,060.70 / $3,672.84
| Facility | | $2,007.82 | $3,060.70 | $3,672.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.42 / $2,007.82 / $2,081.28
| Professional | | $1,836.42 | $2,007.82 | $2,081.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,305.56 / $13,773.15 / $66,111.12
| Facility | | $3,305.56 | $13,773.15 | $66,111.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,938.27 / $3,305.56 / $119,998.80
| Professional | | $2,938.27 | $3,305.56 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,989.45 / $2,938.27 / $7,345.05
| Facility | | $1,989.45 | $2,938.27 | $7,345.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,802.06 / $11,802.06 / $11,802.06
| Professional | | $11,802.06 | $11,802.06 | $11,802.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,224.28 / $3,550.41
| Professional | | $1,028.40 | $1,224.28 | $3,550.41 |