- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $10,232.93 / $23,988.33
| Facility | | $2,290.87 | $10,232.93 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $9,120.11
| Professional | | $676.08 | $676.08 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $11,220.18 / $11,220.18
| Professional | | $10,715.19 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $10,232.93 / $23,988.33
| Facility | | $2,290.87 | $10,232.93 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $10,232.93
| Professional | | $676.08 | $676.08 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $11,481.54 / $28,840.32
| Facility | | $6,918.31 | $11,481.54 | $28,840.32 |