- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $9,120.11 / $21,877.62
| Facility | | $7,943.28 | $9,120.11 | $21,877.62 |
- 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
- $416.87 / $707.95 / $1,318.26
| Facility | | $416.87 | $707.95 | $1,318.26 |
- 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
- $354.81 / $1,230.27 / $3,548.13
| Facility | | $354.81 | $1,230.27 | $3,548.13 |