- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,555.54 / $2,371.25 / $2,845.50
| Facility | | $1,555.54 | $2,371.25 | $2,845.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.75 / $1,555.54 / $1,612.45
| Professional | | $1,422.75 | $1,555.54 | $1,612.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,560.94 / $10,670.63 / $51,219.00
| Facility | | $2,560.94 | $10,670.63 | $51,219.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,276.40 / $2,560.94 / $119,998.80
| Professional | | $2,276.40 | $2,560.94 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,541.31 / $2,276.40 / $5,690.53
| Facility | | $1,541.31 | $2,276.40 | $5,690.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,143.54 / $9,143.54 / $9,143.54
| Professional | | $9,143.54 | $9,143.54 | $9,143.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.74 / $948.50 / $2,750.65
| Professional | | $796.74 | $948.50 | $2,750.65 |