- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,176.83 / $4,176.83 / $4,176.83
| Facility | | $4,176.83 | $4,176.83 | $4,176.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,176.83 / $4,176.83 / $4,176.83
| Professional | | $4,176.83 | $4,176.83 | $4,176.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,132.84 / $15,569.36 / $17,736.47
| Facility | | $14,132.84 | $15,569.36 | $17,736.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,030.87 / $14,153.97 / $15,491.91
| Professional | | $12,030.87 | $14,153.97 | $15,491.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,665.63 / $6,732.28 / $8,465.34
| Professional | | $6,665.63 | $6,732.28 | $8,465.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.08 / $1,900.08 / $3,016.51
| Professional | | $1,900.08 | $1,900.08 | $3,016.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.08 / $1,900.08 / $3,016.51
| Professional | | $1,900.08 | $1,900.08 | $3,016.51 |