- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,225.12 / $5,225.12 / $34,430.76
| Facility | | $5,225.12 | $5,225.12 | $34,430.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,225.12 / $5,225.12 / $5,225.12
| Professional | | $5,225.12 | $5,225.12 | $5,225.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $5,351.02
| Professional | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,711.52 / $9,890.35 / $13,804.58
| Facility | | $7,711.52 | $9,890.35 | $13,804.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,983.80 / $5,246.10 / $5,246.10
| Professional | | $4,983.80 | $5,246.10 | $5,246.10 |