- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46,403.10 / $46,403.10 / $46,403.10
| Facility | | $46,403.10 | $46,403.10 | $46,403.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,065.76 / $6,823.98 / $6,823.98
| Professional | | $6,065.76 | $6,823.98 | $6,823.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,321.08 / $12,813.92 / $27,564.00
| Facility | | $12,321.08 | $12,813.92 | $27,564.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,799.77 / $8,799.77 / $9,671.04
| Professional | | $8,799.77 | $8,799.77 | $9,671.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,719.53 / $15,412.34 / $15,412.34
| Professional | | $8,719.53 | $15,412.34 | $15,412.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,184.52 / $4,549.32 / $12,055.70
| Professional | | $3,184.52 | $4,549.32 | $12,055.70 |