- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,570.40 / $6,456.54
| Facility | | $1,096.48 | $2,570.40 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $22,908.68 / $22,908.68
| Professional | | $2,570.40 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,943.28 / $13,489.63
| Facility | | $3,235.94 | $7,943.28 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $10,232.93
| Facility | | $10,232.93 | $10,232.93 | $10,232.93 |
- 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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,585.78 / $12,302.69
| Facility | | $4,365.16 | $7,585.78 | $12,302.69 |