- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,863.70 / $29,055.20 / $44,571.43
| Facility | | $24,863.70 | $29,055.20 | $44,571.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,260.62 / $9,816.26 / $11,575.78
| Professional | | $9,260.62 | $9,816.26 | $11,575.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,970.40 / $11,970.40 / $11,970.40
| Facility | | $11,970.40 | $11,970.40 | $11,970.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.40 / $58.40 / $58.40
| Professional | | $58.40 | $58.40 | $58.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.00 / $9,858.02 / $11,970.40
| Facility | | $70.00 | $9,858.02 | $11,970.40 |