- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,180.33 / $4,848.06 / $5,817.67
| Facility | | $3,180.33 | $4,848.06 | $5,817.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,908.84 / $3,180.33 / $3,296.69
| Professional | | $2,908.84 | $3,180.33 | $3,296.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,235.91 / $21,816.28 / $104,718.20
| Facility | | $5,235.91 | $21,816.28 | $104,718.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,654.14 / $5,235.91 / $119,998.80
| Professional | | $4,654.14 | $5,235.91 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,151.24 / $3,781.49 / $4,654.14
| Facility | | $3,151.24 | $3,781.49 | $4,654.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,694.13 / $18,694.13 / $18,694.13
| Professional | | $18,694.13 | $18,694.13 | $18,694.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.95 / $1,745.30 / $5,623.75
| Professional | | $1,628.95 | $1,745.30 | $5,623.75 |