- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,620.87 / $18,620.87 / $18,620.87
| Facility | | $18,620.87 | $18,620.87 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,202.26 / $4,265.80
| Professional | | $912.01 | $1,202.26 | $4,265.80 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,621.81 / $1,621.81
| Professional | | $1,479.11 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,621.81 / $1,621.81
| Professional | | $1,047.13 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,778.28 / $2,041.74
| Facility | | $1,659.59 | $1,778.28 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,778.28 / $2,041.74
| Professional | | $1,659.59 | $1,778.28 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,479.11 / $1,698.24
| Facility | | $933.25 | $1,479.11 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,047.13 / $2,187.76
| Professional | | $79.43 | $1,047.13 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,659.59 / $2,454.71
| Professional | | $1,348.96 | $1,659.59 | $2,454.71 |