- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,703.96 / $25,703.96 / $25,703.96
| Facility | | $25,703.96 | $25,703.96 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $1,949.84 / $4,570.88
| Professional | | $407.38 | $1,949.84 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,202.26 / $4,265.80
| Professional | | $870.96 | $1,202.26 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $933.25 / $4,466.84
| Professional | | $562.34 | $933.25 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $10,471.29 / $25,703.96
| Facility | | $6,918.31 | $10,471.29 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,621.81 / $6,760.83
| Professional | | $660.69 | $1,621.81 | $6,760.83 |