- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,787.70 / $16,787.70 / $16,787.70
| Facility | | $16,787.70 | $16,787.70 | $16,787.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.72 / $2,160.50 / $2,394.07
| Professional | | $2,043.72 | $2,160.50 | $2,394.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,094.83 / $3,438.70 / $3,591.11
| Facility | | $3,094.83 | $3,438.70 | $3,591.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,868.47 / $3,868.47 / $3,868.47
| Professional | | $3,868.47 | $3,868.47 | $3,868.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,632.14 / $8,632.14 / $8,632.14
| Facility | | $8,632.14 | $8,632.14 | $8,632.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,335.67 / $2,335.67 / $2,335.67
| Professional | | $2,335.67 | $2,335.67 | $2,335.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $4,210.93
| Professional | | $1,226.23 | $1,751.76 | $4,210.93 |