- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,370.32 / $5,370.32
| Facility | | $1,412.54 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,456.54 / $8,709.64
| Professional | | $3,981.07 | $6,456.54 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,197.01 / $18,197.01 / $18,197.01
| Facility | | $18,197.01 | $18,197.01 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46,773.51 / $46,773.51 / $46,773.51
| Professional | | $46,773.51 | $46,773.51 | $46,773.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $32,359.37
| Facility | | $8,511.38 | $8,511.38 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $602.56 / $1,479.11
| Professional | | $331.13 | $602.56 | $1,479.11 |