- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $12,022.64 / $19,054.61
| Facility | | $3,890.45 | $12,022.64 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $12,882.50 / $16,595.87
| Professional | | $10,715.19 | $12,882.50 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,054.61 / $19,054.61 / $19,952.62
| Facility | | $19,054.61 | $19,054.61 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |