- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,943.28 / $15,135.61
| Facility | | $7,079.46 | $7,943.28 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $6,760.83
| Professional | | $3,890.45 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $11,220.18 / $21,877.62
| Facility | | $8,709.64 | $11,220.18 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $11,748.98 / $12,302.69
| Professional | | $10,715.19 | $11,748.98 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $7,413.10 / $13,803.84
| Facility | | $3,890.45 | $7,413.10 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $8,511.38 / $12,589.25
| Facility | | $7,079.46 | $8,511.38 | $12,589.25 |