- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $8,709.64 / $10,471.29
| Facility | | $1,659.59 | $8,709.64 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $18,197.01 / $18,197.01
| Professional | | $1,698.24 | $18,197.01 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Professional | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $21,379.62 / $43,651.58
| Facility | | $19,952.62 | $21,379.62 | $43,651.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $21,379.62 / $28,840.32
| Facility | | $9,549.93 | $21,379.62 | $28,840.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67,608.30 / $67,608.30 / $67,608.30
| Facility | | $67,608.30 | $67,608.30 | $67,608.30 |