- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $7,244.36
| Facility | | $3,981.07 | $3,981.07 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $2,187.76 / $4,073.80
| Professional | | $741.31 | $2,187.76 | $4,073.80 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $15,848.93 / $16,595.87
| Facility | | $11,748.98 | $15,848.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,748.98 / $15,848.93 / $16,595.87
| Professional | | $11,748.98 | $15,848.93 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $85.11
| Professional | | $79.43 | $79.43 | $85.11 |