- 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
- $1,778.28 / $15,848.93 / $15,848.93
| Professional | | $1,778.28 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,135.61 / $19,952.62 / $38,904.51
| Facility | | $15,135.61 | $19,952.62 | $38,904.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,197.01 / $19,952.62 / $20,892.96
| Professional | | $18,197.01 | $19,952.62 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $15,488.17 / $30,199.52
| Facility | | $9,549.93 | $15,488.17 | $30,199.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $13,489.63 / $24,547.09
| Facility | | $9,120.11 | $13,489.63 | $24,547.09 |