- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,306.40 / $14,306.40 / $14,306.40
| Facility | | $14,306.40 | $14,306.40 | $14,306.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.12 / $2,103.89 / $2,103.89
| Professional | | $1,870.12 | $2,103.89 | $2,103.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,798.68 / $3,950.62 / $8,497.99
| Facility | | $3,798.68 | $3,950.62 | $8,497.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.96 / $7,394.67 / $18,214.36
| Professional | | $1,408.96 | $7,394.67 | $18,214.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,688.30 / $4,751.74 / $4,751.74
| Professional | | $2,688.30 | $4,751.74 | $4,751.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.81 / $1,402.59 / $3,716.86
| Professional | | $981.81 | $1,402.59 | $3,716.86 |