- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,772.37 / $16,595.87
| Facility | | $6,760.83 | $9,772.37 | $16,595.87 |
- 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
- $2,187.76 / $8,317.64 / $13,803.84
| Facility | | $2,187.76 | $8,317.64 | $13,803.84 |
- 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
- $19,054.61 / $28,183.83 / $32,359.37
| Facility | | $19,054.61 | $28,183.83 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $22,387.21 / $37,153.52
| Facility | | $8,317.64 | $22,387.21 | $37,153.52 |