- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,770.50 / $16,770.50 / $16,770.50
| Facility | | $16,770.50 | $16,770.50 | $16,770.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,091.65 / $3,435.17 / $3,587.42
| Facility | | $3,091.65 | $3,435.17 | $3,587.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,864.50 / $3,864.50 / $3,864.50
| Professional | | $3,864.50 | $3,864.50 | $3,864.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,623.87 / $8,623.87 / $8,623.87
| Facility | | $8,623.87 | $8,623.87 | $8,623.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,333.28 / $2,333.28 / $2,333.28
| Professional | | $2,333.28 | $2,333.28 | $2,333.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.97 / $1,749.96 / $4,206.60
| Professional | | $1,224.97 | $1,749.96 | $4,206.60 |