- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $11,748.98 / $40,738.03
| Facility | | $4,570.88 | $11,748.98 | $40,738.03 |
- 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
- $16,595.87 / $39,810.72 / $48,977.88
| Facility | | $16,595.87 | $39,810.72 | $48,977.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $39,810.72 / $72,443.60
| Facility | | $1,737.80 | $39,810.72 | $72,443.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $12,589.25 / $56,234.13
| Facility | | $5,370.32 | $12,589.25 | $56,234.13 |