- 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
- $719.07 / $2,394.07 / $2,919.60
| Professional | | $719.07 | $2,394.07 | $2,919.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $3,438.70 / $3,737.09
| Facility | | $2,919.60 | $3,438.70 | $3,737.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.25 / $2,189.69 / $2,321.08
| Professional | | $1,861.25 | $2,189.69 | $2,321.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,749.03 / $7,749.03 / $7,749.03
| Facility | | $7,749.03 | $7,749.03 | $7,749.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.97 / $3,354.80 / $4,193.50
| Professional | | $1,707.97 | $3,354.80 | $4,193.50 |
- 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 |