- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $8,709.64 / $10,715.19
| Facility | | $1,698.24 | $8,709.64 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $22,908.68 / $22,908.68
| Professional | | $1,698.24 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,118.86 / $27,542.29 / $56,234.13
| Facility | | $25,118.86 | $27,542.29 | $56,234.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $15,135.61 / $22,908.68
| Facility | | $6,760.83 | $15,135.61 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43,651.58 / $43,651.58 / $43,651.58
| Facility | | $43,651.58 | $43,651.58 | $43,651.58 |