- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,772.37 / $16,595.87
| Facility | | $6,760.83 | $9,772.37 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Professional | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $2,951.21
| Facility | | $2,041.74 | $2,398.83 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $26,915.35 / $63,095.73
| Facility | | $4,265.80 | $26,915.35 | $63,095.73 |