- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $14,791.08
| Facility | | $10,715.19 | $10,715.19 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,244.36 / $10,715.19
| Professional | | $5,623.41 | $7,244.36 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $11,481.54
| Professional | | $7,585.78 | $7,585.78 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,760.83 / $15,848.93
| Facility | | $5,495.41 | $6,760.83 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $8,511.38
| Facility | | $7,585.78 | $7,585.78 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,128.61 / $8,511.38
| Professional | | $3,548.13 | $5,128.61 | $8,511.38 |