- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $15,135.61 / $31,622.78
| Facility | | $7,943.28 | $15,135.61 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $15,135.61
| Professional | | $9,120.11 | $9,120.11 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $8,511.38 / $15,488.17
| Facility | | $5,011.87 | $8,511.38 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $54.95
| Professional | | $30.20 | $30.20 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $17,378.01 / $26,302.68
| Facility | | $6,309.57 | $17,378.01 | $26,302.68 |