- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $9,772.37
| Facility | | $1,513.56 | $1,819.70 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,479.11 / $1,513.56
| Professional | | $1,202.26 | $1,479.11 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,606.93 / $6,606.93
| Professional | | $4,786.30 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Professional | | $6,606.93 | $6,606.93 | $6,606.93 |