- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,508.30 / $16,508.30 / $16,508.30
| Facility | | $16,508.30 | $16,508.30 | $16,508.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.75 / $1,573.82 / $2,354.21
| Professional | | $1,488.75 | $1,573.82 | $2,354.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.78 / $3,381.46 / $3,531.33
| Facility | | $2,126.78 | $3,381.46 | $3,531.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.26 / $2,153.25 / $2,153.25
| Professional | | $1,830.26 | $2,153.25 | $2,153.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,700.71 / $3,700.71 / $7,620.03
| Facility | | $3,700.71 | $3,700.71 | $7,620.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.17 / $3,809.68 / $7,771.71
| Professional | | $1,208.17 | $3,809.68 | $7,771.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.39 / $1,722.60 / $3,067.45
| Professional | | $1,063.39 | $1,722.60 | $3,067.45 |