- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,698.24 / $8,128.31
| Facility | | $851.14 | $1,698.24 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $2,041.74
| Professional | | $1,047.13 | $1,047.13 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $977.24 / $1,548.82
| Facility | | $707.95 | $977.24 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $6,918.31 / $10,471.29
| Facility | | $2,187.76 | $6,918.31 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,840.32 / $28,840.32 / $45,708.82
| Facility | | $28,840.32 | $28,840.32 | $45,708.82 |