- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,269.80 / $22,269.80 / $22,269.80
| Facility | | $22,269.80 | $22,269.80 | $22,269.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $2,866.02 / $3,175.86
| Professional | | $2,711.10 | $2,866.02 | $3,175.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,873.00 / $4,561.62 / $4,957.43
| Facility | | $3,873.00 | $4,561.62 | $4,957.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,904.75 / $2,904.75 / $4,732.42
| Professional | | $2,904.75 | $2,904.75 | $4,732.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,451.73 / $11,451.73 / $11,451.73
| Facility | | $11,451.73 | $11,451.73 | $11,451.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.88 / $2,168.88 / $2,168.88
| Professional | | $2,168.88 | $2,168.88 | $2,168.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,323.80 / $5,586.03
| Professional | | $1,626.66 | $2,323.80 | $5,586.03 |