- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $16,595.87 / $16,595.87
| Facility | | $10,471.29 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,570.40 / $2,691.53
| Professional | | $2,398.83 | $2,570.40 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,265.80 / $4,570.88
| Facility | | $3,801.89 | $4,265.80 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Professional | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $5,248.07
| Professional | | $1,548.82 | $2,187.76 | $5,248.07 |