- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,269.80 / $22,269.80 / $22,269.80
| Facility | | $22,269.80 | $22,269.80 | $22,269.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $2,866.02 / $3,175.86
| Professional | | $2,711.10 | $2,866.02 | $3,175.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,105.46 / $4,561.62 / $4,763.79
| Facility | | $4,105.46 | $4,561.62 | $4,763.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,131.72 / $5,131.72 / $5,131.72
| Professional | | $5,131.72 | $5,131.72 | $5,131.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,279.48 / $10,279.48 / $10,279.48
| Facility | | $10,279.48 | $10,279.48 | $10,279.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,265.71 / $2,265.71 / $2,265.71
| Professional | | $2,265.71 | $2,265.71 | $2,265.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,323.80 / $5,586.03
| Professional | | $1,626.66 | $2,323.80 | $5,586.03 |