- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,264.65 / $3,264.65 / $3,264.65
| Facility | | $3,264.65 | $3,264.65 | $3,264.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.58 / $1,545.58 / $1,545.58
| Professional | | $1,545.58 | $1,545.58 | $1,545.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170,098.30 / $170,098.30 / $170,098.30
| Facility | | $170,098.30 | $170,098.30 | $170,098.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125,998.74 / $151,873.49 / $187,108.13
| Professional | | $125,998.74 | $151,873.49 | $187,108.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.66 / $660.66 / $660.66
| Professional | | $660.66 | $660.66 | $660.66 |