- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,623.41 / $18,197.01
| Facility | | $4,265.80 | $5,623.41 | $18,197.01 |
- 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
- $11,748.98 / $19,498.45 / $85,113.80
| Facility | | $11,748.98 | $19,498.45 | $85,113.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $9,120.11 / $19,498.45
| Facility | | $8,317.64 | $9,120.11 | $19,498.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $20,892.96 / $45,708.82
| Facility | | $4,786.30 | $20,892.96 | $45,708.82 |