- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,585.78 / $8,912.51
| Professional | | $2,398.83 | $7,585.78 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46,773.51 / $81,283.05 / $95,499.26
| Facility | | $46,773.51 | $81,283.05 | $95,499.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,488.17 / $15,488.17 / $15,488.17
| Facility | | $15,488.17 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,488.17 / $15,488.17 / $15,488.17
| Professional | | $15,488.17 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $16,982.44 / $52,480.75
| Facility | | $16,982.44 | $16,982.44 | $52,480.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,982.44 / $16,982.44 / $52,480.75
| Professional | | $16,982.44 | $16,982.44 | $52,480.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $7,079.46 / $15,488.17
| Facility | | $6,606.93 | $7,079.46 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $15,488.17 / $17,782.79
| Professional | | $79.43 | $15,488.17 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,479.11 / $3,019.95
| Professional | | $933.25 | $1,479.11 | $3,019.95 |