- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,897.79 / $11,220.18
| Facility | | $1,380.38 | $4,897.79 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $19,054.61 / $19,054.61
| Professional | | $831.76 | $19,054.61 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $40,738.03 / $57,543.99
| Facility | | $16,982.44 | $40,738.03 | $57,543.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Professional | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $13,803.84 / $20,417.38
| Facility | | $6,456.54 | $13,803.84 | $20,417.38 |