- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,427.09 / $2,487.77 / $2,578.78
| Professional | | $2,427.09 | $2,487.77 | $2,578.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,700.29 / $10,921.90 / $81,914.22
| Facility | | $2,700.29 | $10,921.90 | $81,914.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,615.12 / $2,700.29 / $119,998.80
| Professional | | $2,615.12 | $2,700.29 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,640.63 / $3,640.63 / $3,640.63
| Facility | | $3,640.63 | $3,640.63 | $3,640.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,623.21 / $14,623.21 / $14,623.21
| Professional | | $14,623.21 | $14,623.21 | $14,623.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.22 / $1,516.93 / $4,854.18
| Professional | | $1,274.22 | $1,516.93 | $4,854.18 |