- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,645.75 / $4,374.89 / $4,374.89
| Facility | | $3,645.75 | $4,374.89 | $4,374.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,937.41 / $16,405.88 / $78,748.20
| Facility | | $3,937.41 | $16,405.88 | $78,748.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,499.92 / $3,937.41 / $119,998.80
| Professional | | $3,499.92 | $3,937.41 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,369.73 / $3,499.92 / $8,749.07
| Facility | | $2,369.73 | $3,499.92 | $8,749.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,058.01 / $14,058.01 / $14,058.01
| Professional | | $14,058.01 | $14,058.01 | $14,058.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.97 / $1,458.30 / $4,229.07
| Professional | | $1,224.97 | $1,458.30 | $4,229.07 |