- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,309.57 / $9,549.93
| Facility | | $4,570.88 | $6,309.57 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,054.61 / $19,054.61 / $19,054.61
| Professional | | $19,054.61 | $19,054.61 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $17,378.01 / $31,622.78
| Facility | | $8,912.51 | $17,378.01 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Professional | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $12,589.25 / $21,877.62
| Facility | | $8,912.51 | $12,589.25 | $21,877.62 |