- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,175.86 / $4,841.25 / $5,809.50
| Facility | | $3,175.86 | $4,841.25 | $5,809.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,904.75 / $3,175.86 / $3,292.05
| Professional | | $2,904.75 | $3,175.86 | $3,292.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,228.55 / $21,785.63 / $104,571.00
| Facility | | $5,228.55 | $21,785.63 | $104,571.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,647.60 / $5,228.55 / $119,998.80
| Professional | | $4,647.60 | $5,228.55 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.81 / $4,647.60 / $11,618.03
| Facility | | $3,146.81 | $4,647.60 | $11,618.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,667.86 / $18,667.86 / $18,667.86
| Professional | | $18,667.86 | $18,667.86 | $18,667.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $1,936.50 / $5,615.85
| Professional | | $1,626.66 | $1,936.50 | $5,615.85 |