- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,511.38 / $12,302.69
| Facility | | $4,570.88 | $8,511.38 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $13,489.63 / $16,595.87
| Professional | | $6,025.60 | $13,489.63 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $19,498.45 / $21,379.62
| Facility | | $16,595.87 | $19,498.45 | $21,379.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,302.68 / $42,657.95 / $66,069.34
| Facility | | $26,302.68 | $42,657.95 | $66,069.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,951.21 / $3,235.94
| Professional | | $2,754.23 | $2,951.21 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,772.37 / $25,118.86
| Facility | | $4,570.88 | $9,772.37 | $25,118.86 |