- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,413.10 / $10,964.78
| Facility | | $3,981.07 | $7,413.10 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $6,606.93 / $12,882.50
| Facility | | $1,698.24 | $6,606.93 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $53,703.18
| Facility | | $64.57 | $64.57 | $53,703.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50,118.72 / $53,703.18 / $75,857.76
| Facility | | $50,118.72 | $53,703.18 | $75,857.76 |