- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,451.80 / $2,213.10 / $2,655.72
| Facility | | $1,451.80 | $2,213.10 | $2,655.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.86 / $1,451.80 / $1,504.91
| Professional | | $1,327.86 | $1,451.80 | $1,504.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,390.15 / $9,958.95 / $47,802.96
| Facility | | $2,390.15 | $9,958.95 | $47,802.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,124.58 / $2,390.15 / $119,998.80
| Professional | | $2,124.58 | $2,390.15 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,438.51 / $1,726.22 / $2,124.58
| Facility | | $1,438.51 | $1,726.22 | $2,124.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,533.70 / $8,533.70 / $8,533.70
| Professional | | $8,533.70 | $8,533.70 | $8,533.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $743.60 / $743.60 / $743.60
| Facility | | $743.60 | $743.60 | $743.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.60 / $885.24 / $2,567.19
| Professional | | $743.60 | $885.24 | $2,567.19 |