- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,241.22 / $11,995.87 / $24,068.03
| Facility | | $4,241.22 | $11,995.87 | $24,068.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.27 / $912.27 / $912.27
| Professional | | $912.27 | $912.27 | $912.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,547.24 / $20,448.87 / $39,554.72
| Facility | | $15,547.24 | $20,448.87 | $39,554.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.27 / $1,596.47 / $26,581.96
| Facility | | $912.27 | $1,596.47 | $26,581.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,148.00 / $9,696.00 / $15,622.00
| Facility | | $8,148.00 | $9,696.00 | $15,622.00 |