- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,929.40 / $28,929.40 / $28,929.40
| Facility | | $28,929.40 | $28,929.40 | $28,929.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,528.08 / $4,528.08 / $4,528.08
| Professional | | $4,528.08 | $4,528.08 | $4,528.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,773.40 / $5,925.75 / $6,188.38
| Facility | | $3,773.40 | $5,925.75 | $6,188.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,773.40 / $3,773.40 / $3,773.40
| Professional | | $3,773.40 | $3,773.40 | $3,773.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,353.51 / $13,353.51 / $13,353.51
| Facility | | $13,353.51 | $13,353.51 | $13,353.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,943.25 / $6,676.39 / $6,676.39
| Professional | | $2,943.25 | $6,676.39 | $6,676.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.10 / $3,018.72 / $7,256.50
| Professional | | $2,113.10 | $3,018.72 | $7,256.50 |