- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,649.50 / $4,050.00 / $4,050.00
| Facility | | $3,649.50 | $4,050.00 | $4,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,189.69 / $2,394.07 / $2,481.66
| Professional | | $2,189.69 | $2,394.07 | $2,481.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,598.66 / $10,510.56 / $78,829.20
| Facility | | $2,598.66 | $10,510.56 | $78,829.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,516.69 / $3,941.46 / $119,998.80
| Professional | | $2,516.69 | $3,941.46 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,372.17 / $3,503.52 / $8,758.07
| Facility | | $2,372.17 | $3,503.52 | $8,758.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,072.47 / $14,072.47 / $14,072.47
| Professional | | $14,072.47 | $14,072.47 | $14,072.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,946.76 / $4,946.76 / $4,946.76
| Facility | | $4,946.76 | $4,946.76 | $4,946.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,459.80 / $4,233.42
| Professional | | $1,226.23 | $1,459.80 | $4,233.42 |