- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $8,511.38 / $16,218.10
| Facility | | $4,786.30 | $8,511.38 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $15,488.17 / $30,199.52
| Facility | | $11,748.98 | $15,488.17 | $30,199.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,892.96 / $20,892.96 / $20,892.96
| Facility | | $20,892.96 | $20,892.96 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,715.35 / $15,488.17
| Facility | | $2,137.96 | $3,715.35 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,370.32 / $7,585.78
| Professional | | $4,466.84 | $5,370.32 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,892.96 / $20,892.96 / $20,892.96
| Facility | | $20,892.96 | $20,892.96 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $13,489.63 / $26,302.68
| Facility | | $8,709.64 | $13,489.63 | $26,302.68 |