- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,387.44 / $4,064.92 / $4,064.92
| Facility | | $3,387.44 | $4,064.92 | $4,064.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.46 / $2,167.96 / $2,303.46
| Professional | | $2,032.46 | $2,167.96 | $2,303.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,658.43 / $15,243.47 / $73,168.66
| Facility | | $3,658.43 | $15,243.47 | $73,168.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,251.94 / $3,658.43 / $119,998.80
| Professional | | $3,251.94 | $3,658.43 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,201.84 / $3,251.94 / $8,129.18
| Facility | | $2,201.84 | $3,251.94 | $8,129.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,061.96 / $13,061.96 / $13,061.96
| Professional | | $13,061.96 | $13,061.96 | $13,061.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.18 / $1,354.98 / $4,335.92
| Professional | | $1,138.18 | $1,354.98 | $4,335.92 |