- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,805.33 / $2,752.03 / $3,302.43
| Facility | | $1,805.33 | $2,752.03 | $3,302.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.22 / $1,783.31 / $1,805.33
| Professional | | $1,651.22 | $1,783.31 | $1,805.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,972.19 / $12,384.11 / $59,443.74
| Facility | | $2,972.19 | $12,384.11 | $59,443.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,641.94 / $2,972.19 / $119,998.80
| Professional | | $2,641.94 | $2,972.19 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,788.81 / $2,641.94 / $2,641.94
| Facility | | $1,788.81 | $2,641.94 | $2,641.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.63 / $3,162.03 / $10,611.81
| Professional | | $2,529.63 | $3,162.03 | $10,611.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.68 / $990.73 / $3,192.35
| Professional | | $924.68 | $990.73 | $3,192.35 |