- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $16,982.44 / $27,542.29
| Facility | | $14,454.40 | $16,982.44 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,760.83 / $7,762.47
| Professional | | $5,495.41 | $6,760.83 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Facility | | $7,079.46 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $7,079.46
| Facility | | $4,897.79 | $4,897.79 | $7,079.46 |