- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $8,709.64 / $23,988.33
| Facility | | $7,943.28 | $8,709.64 | $23,988.33 |
- 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
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Professional | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,135.61 / $15,135.61 / $15,135.61
| Facility | | $15,135.61 | $15,135.61 | $15,135.61 |