- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $28,183.83 / $42,657.95
| Facility | | $7,943.28 | $28,183.83 | $42,657.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,943.28 / $7,943.28
| Professional | | $3,801.89 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,943.28 / $10,715.19
| Facility | | $3,801.89 | $7,943.28 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $5,888.44
| Facility | | $5,888.44 | $5,888.44 | $5,888.44 |