- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,421.13 / $20,021.25 / $21,040.41
| Facility | | $16,421.13 | $20,021.25 | $21,040.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.84 / $2,501.51 / $2,614.23
| Professional | | $2,306.84 | $2,501.51 | $2,614.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,536.46 / $4,536.46 / $4,536.46
| Facility | | $4,536.46 | $4,536.46 | $4,536.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.99 / $3,855.99 / $4,536.46
| Professional | | $3,855.99 | $3,855.99 | $4,536.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,821.68 / $25,821.68 / $25,821.68
| Facility | | $25,821.68 | $25,821.68 | $25,821.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,524.91 / $2,948.67 / $4,212.39
| Professional | | $2,524.91 | $2,948.67 | $4,212.39 |