- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,344.23 / $4,265.80
| Facility | | $1,862.09 | $2,344.23 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $2,691.53
| Professional | | $1,148.15 | $1,380.38 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $64,565.42 / $95,499.26
| Facility | | $1,862.09 | $64,565.42 | $95,499.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $79.43 / $1,288.25
| Professional | | $60.26 | $79.43 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,258.93 / $1,258.93
| Professional | | $1,202.26 | $1,258.93 | $1,258.93 |