- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $8,511.38 / $8,511.38
| Facility | | $1,412.54 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $8,912.51 / $10,232.93
| Professional | | $891.25 | $8,912.51 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $19,952.62 / $19,952.62
| Facility | | $19,952.62 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51,286.14 / $51,286.14 / $51,286.14
| Professional | | $51,286.14 | $51,286.14 | $51,286.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $51,286.14
| Facility | | $8,511.38 | $8,511.38 | $51,286.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $741.31 / $1,548.82
| Professional | | $478.63 | $741.31 | $1,548.82 |