- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $10,964.78 / $18,197.01
| Facility | | $8,912.51 | $10,964.78 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Professional | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,801.89 / $7,413.10
| Facility | | $2,398.83 | $3,801.89 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $4,570.88
| Facility | | $3,548.13 | $3,548.13 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $16,595.87 / $19,054.61
| Facility | | $11,220.18 | $16,595.87 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $11,220.18 / $17,378.01
| Facility | | $2,754.23 | $11,220.18 | $17,378.01 |