- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,527.84 / $2,329.02 / $2,794.83
| Facility | | $1,527.84 | $2,329.02 | $2,794.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,397.42 / $1,527.84 / $1,583.74
| Professional | | $1,397.42 | $1,527.84 | $1,583.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,515.35 / $10,480.61 / $50,306.94
| Facility | | $2,515.35 | $10,480.61 | $50,306.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,235.86 / $2,515.35 / $119,998.80
| Professional | | $2,235.86 | $2,515.35 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.86 / $1,816.64 / $2,235.86
| Facility | | $1,513.86 | $1,816.64 | $2,235.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,980.71 / $8,980.71 / $8,980.71
| Professional | | $8,980.71 | $8,980.71 | $8,980.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $931.61 / $2,701.67
| Professional | | $782.55 | $931.61 | $2,701.67 |