- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,702.16 / $2,594.75 / $3,113.70
| Facility | | $1,702.16 | $2,594.75 | $3,113.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.85 / $1,681.40 / $1,702.16
| Professional | | $1,556.85 | $1,681.40 | $1,702.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,802.33 / $11,676.38 / $56,046.60
| Facility | | $2,802.33 | $11,676.38 | $56,046.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,490.96 / $2,802.33 / $119,998.80
| Professional | | $2,490.96 | $2,802.33 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,686.59 / $2,490.96 / $2,490.96
| Facility | | $1,686.59 | $2,490.96 | $2,490.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,385.08 / $2,981.34 / $10,005.36
| Professional | | $2,385.08 | $2,981.34 | $10,005.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $871.84 / $871.84 / $871.84
| Facility | | $871.84 | $871.84 | $871.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $934.11 / $2,802.33
| Professional | | $871.84 | $934.11 | $2,802.33 |