- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,772.37 / $16,595.87
| Facility | | $6,760.83 | $9,772.37 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Professional | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.54 / $2,398.83 / $7,585.78
| Facility | | $57.54 | $2,398.83 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $17,378.01 / $25,703.96
| Facility | | $2,884.03 | $17,378.01 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Professional | | $1,995.26 | $1,995.26 | $1,995.26 |