- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,606.25 / $17,068.56 / $26,183.61
| Facility | | $14,606.25 | $17,068.56 | $26,183.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,440.13 / $5,766.53 / $6,800.16
| Professional | | $5,440.13 | $5,766.53 | $6,800.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,134.16 / $7,134.16 / $7,134.16
| Facility | | $7,134.16 | $7,134.16 | $7,134.16 |
- 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 / $4,911.77 / $7,134.16
| Facility | | $70.00 | $4,911.77 | $7,134.16 |