- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $4,073.80
| Facility | | $3,630.78 | $3,630.78 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $1,862.09
| Professional | | $218.78 | $218.78 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81,283.05 / $81,283.05 / $81,283.05
| Facility | | $81,283.05 | $81,283.05 | $81,283.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72,443.60 / $72,443.60 / $72,443.60
| Professional | | $72,443.60 | $72,443.60 | $72,443.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $34.67
| Facility | | $34.67 | $34.67 | $34.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $691.83
| Facility | | $457.09 | $457.09 | $691.83 |