- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.36 / $3,370.84 / $13,557.62
| Facility | | $3,143.36 | $3,370.84 | $13,557.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $82,011.67 / $82,011.67 / $82,011.67
| Facility | | $82,011.67 | $82,011.67 | $82,011.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72,899.27 / $72,899.27 / $72,899.27
| Professional | | $72,899.27 | $72,899.27 | $72,899.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $863.88 / $1,596.98 / $2,405.52
| Facility | | $863.88 | $1,596.98 | $2,405.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.85 / $772.85 / $772.85
| Professional | | $772.85 | $772.85 | $772.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $672.56 / $672.56 / $672.56
| Facility | | $672.56 | $672.56 | $672.56 |