- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,752.61 / $4,503.14 / $4,503.14
| Facility | | $3,752.61 | $4,503.14 | $4,503.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,052.82 / $16,886.75 / $81,056.44
| Facility | | $4,052.82 | $16,886.75 | $81,056.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,602.51 / $4,052.82 / $119,998.80
| Professional | | $3,602.51 | $4,052.82 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,439.19 / $3,602.51 / $9,005.53
| Facility | | $2,439.19 | $3,602.51 | $9,005.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,470.07 / $14,470.07 / $14,470.07
| Professional | | $14,470.07 | $14,470.07 | $14,470.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.88 / $1,501.05 / $4,353.03
| Professional | | $1,260.88 | $1,501.05 | $4,353.03 |