- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Facility | | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Professional | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $426.58 / $467.74
| Professional | | $363.08 | $426.58 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $56,234.13 / $83,176.38
| Facility | | $12,302.69 | $56,234.13 | $83,176.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52,480.75 / $74,131.02 / $104,712.85
| Professional | | $52,480.75 | $74,131.02 | $104,712.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $954.99
| Facility | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Professional | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $44.67 / $44.67
| Professional | | $44.67 | $44.67 | $44.67 |