- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,025.60 / $12,302.69
| Facility | | $2,951.21 | $6,025.60 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,912.51 / $18,197.01 / $18,197.01
| Professional | | $8,912.51 | $18,197.01 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,197.01 / $33,113.11 / $69,183.10
| Facility | | $18,197.01 | $33,113.11 | $69,183.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $12,022.64
| Professional | | $11,748.98 | $11,748.98 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,489.63 / $19,054.61 / $32,359.37
| Facility | | $13,489.63 | $19,054.61 | $32,359.37 |