- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $7,762.47 / $16,595.87
| Facility | | $4,677.35 | $7,762.47 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $9,120.11
| Professional | | $7,244.36 | $7,244.36 | $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
- $3,019.95 / $13,182.57 / $23,442.29
| Facility | | $3,019.95 | $13,182.57 | $23,442.29 |