- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,154.48 / $10,154.48 / $10,154.48
| Facility | | $10,154.48 | $10,154.48 | $10,154.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,123.58 / $9,556.43 / $12,319.90
| Professional | | $8,123.58 | $9,556.43 | $12,319.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.04 / $2,087.40 / $7,144.38
| Facility | | $1,005.04 | $2,087.40 | $7,144.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.04 / $1,082.34 / $7,693.95
| Professional | | $1,005.04 | $1,082.34 | $7,693.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,613.42 / $14,613.42 / $14,613.42
| Facility | | $14,613.42 | $14,613.42 | $14,613.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.81 / $10,777.03 / $61,112.11
| Professional | | $1,092.81 | $10,777.03 | $61,112.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.69 / $7,543.11 / $13,469.84
| Professional | | $5,495.69 | $7,543.11 | $13,469.84 |