- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $15,848.93 / $61,659.50
| Facility | | $15,848.93 | $15,848.93 | $61,659.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,125.38 / $15,848.93 / $15,848.93
| Professional | | $14,125.38 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,378.01 / $20,892.96 / $28,183.83
| Facility | | $17,378.01 | $20,892.96 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,218.10
| Professional | | $16,218.10 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $20,892.96 / $26,915.35
| Facility | | $15,848.93 | $20,892.96 | $26,915.35 |