- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $9,332.54 / $18,620.87
| Facility | | $2,238.72 | $9,332.54 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $19,054.61
| Professional | | $933.25 | $933.25 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,197.01 / $41,686.94 / $97,723.72
| Facility | | $18,197.01 | $41,686.94 | $97,723.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.57 / $4.57 / $4.57
| Professional | | $4.57 | $4.57 | $4.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $16,982.44 / $24,547.09
| Facility | | $8,912.51 | $16,982.44 | $24,547.09 |