- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,433.70 / $14,433.70 / $14,433.70
| Facility | | $14,433.70 | $14,433.70 | $14,433.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.37 / $2,169.31 / $2,293.27
| Professional | | $2,058.37 | $2,169.31 | $2,293.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,956.53 / $3,087.56 / $3,213.07
| Facility | | $2,956.53 | $3,087.56 | $3,213.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,882.66 / $1,882.66 / $3,786.70
| Professional | | $1,882.66 | $1,882.66 | $3,786.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,402.72 / $7,402.72 / $7,402.72
| Facility | | $7,402.72 | $7,402.72 | $7,402.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.00 / $3,700.97 / $3,700.97
| Professional | | $1,478.00 | $3,700.97 | $3,700.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,859.41 / $4,469.72
| Professional | | $1,054.29 | $1,859.41 | $4,469.72 |