- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,463.36 / $10,506.16 / $21,899.37
| Facility | | $5,463.36 | $10,506.16 | $21,899.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,888.42 / $3,888.42 / $3,888.42
| Professional | | $3,888.42 | $3,888.42 | $3,888.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,646.56 / $11,718.32 / $21,998.27
| Facility | | $8,646.56 | $11,718.32 | $21,998.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,888.42 / $6,610.31 / $11,511.10
| Facility | | $3,888.42 | $6,610.31 | $11,511.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,729.76 / $14,075.71 / $18,376.62
| Facility | | $11,729.76 | $14,075.71 | $18,376.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,777.00 / $8,220.00 / $9,696.00
| Facility | | $6,777.00 | $8,220.00 | $9,696.00 |