- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $7,079.46 / $11,481.54
| Facility | | $2,884.03 | $7,079.46 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $9,332.54 / $11,220.18
| Professional | | $1,737.80 | $9,332.54 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $7,413.10 / $9,332.54
| Facility | | $6,606.93 | $7,413.10 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,218.10
| Facility | | $16,218.10 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $7,413.10 / $14,125.38
| Facility | | $3,890.45 | $7,413.10 | $14,125.38 |