- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $13,182.57
| Facility | | $7,943.28 | $7,943.28 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,943.28 / $7,943.28
| Professional | | $7,079.46 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,949.84 / $3,801.89
| Facility | | $1,479.11 | $1,949.84 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $8,128.31 / $14,791.08
| Facility | | $5,888.44 | $8,128.31 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $5,248.07
| Professional | | $3,801.89 | $3,801.89 | $5,248.07 |