- 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 / $18,197.01 / $18,197.01
| Professional | | $2,570.40 | $18,197.01 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $10,471.29 / $16,595.87
| Facility | | $4,365.16 | $10,471.29 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,488.17 / $15,488.17 / $15,488.17
| Facility | | $15,488.17 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66,069.34 / $66,069.34 / $66,069.34
| Facility | | $66,069.34 | $66,069.34 | $66,069.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,232.93 / $19,952.62
| Facility | | $6,456.54 | $10,232.93 | $19,952.62 |