- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,545.58 / $1,545.58 / $5,208.60
| Facility | | $1,545.58 | $1,545.58 | $5,208.60 |
- 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
- $65,624.34 / $121,498.80 / $222,747.80
| Facility | | $65,624.34 | $121,498.80 | $222,747.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104,998.95 / $104,998.95 / $127,498.73
| Professional | | $104,998.95 | $104,998.95 | $127,498.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.66 / $660.66 / $660.66
| Professional | | $660.66 | $660.66 | $660.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.66 / $660.66 / $660.66
| Professional | | $660.66 | $660.66 | $660.66 |