- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64,565.42 / $83,176.38 / $95,499.26
| Facility | | $64,565.42 | $83,176.38 | $95,499.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $446.68 / $457.09
| Facility | | $323.59 | $446.68 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $446.68 / $457.09
| Professional | | $323.59 | $446.68 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $85.11
| Professional | | $79.43 | $79.43 | $85.11 |