- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,372.80 / $18,372.80 / $18,372.80
| Facility | | $18,372.80 | $18,372.80 | $18,372.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,701.88 / $3,002.09 / $3,002.09
| Professional | | $2,701.88 | $3,002.09 | $3,002.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,878.39 / $5,073.54 / $10,913.23
| Facility | | $4,878.39 | $5,073.54 | $10,913.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,484.29 / $3,484.29 / $3,829.27
| Professional | | $3,484.29 | $3,484.29 | $3,829.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.40 / $6,102.35 / $6,102.35
| Professional | | $3,452.40 | $6,102.35 | $6,102.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.88 / $1,801.25 / $4,773.32
| Professional | | $1,260.88 | $1,801.25 | $4,773.32 |