- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,834.13 / $5,909.48 / $13,841.56
| Facility | | $2,834.13 | $5,909.48 | $13,841.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.62 / $951.62 / $951.62
| Professional | | $951.62 | $951.62 | $951.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,535.24 / $21,072.03 / $36,980.03
| Facility | | $14,535.24 | $21,072.03 | $36,980.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.09 / $3,044.00 / $7,934.00
| Facility | | $1,167.09 | $3,044.00 | $7,934.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,380.00 / $4,380.00 / $4,380.00
| Professional | | $4,380.00 | $4,380.00 | $4,380.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $3,726.00 / $7,934.00
| Facility | | $3,044.00 | $3,726.00 | $7,934.00 |