- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,495.41 / $5,495.41
| Facility | | $3,981.07 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,466.84
| Professional | | $3,981.07 | $3,981.07 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33,113.11 / $58,884.37 / $95,499.26
| Facility | | $33,113.11 | $58,884.37 | $95,499.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44,668.36 / $44,668.36 / $44,668.36
| Professional | | $44,668.36 | $44,668.36 | $44,668.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,466.84 / $5,495.41
| Facility | | $3,981.07 | $4,466.84 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,466.84
| Professional | | $3,981.07 | $3,981.07 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $77.62
| Professional | | $30.20 | $30.20 | $77.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52,480.75 / $64,565.42 / $95,499.26
| Facility | | $52,480.75 | $64,565.42 | $95,499.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44,668.36 / $69,183.10 / $72,443.60
| Professional | | $44,668.36 | $69,183.10 | $72,443.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $51,286.14 / $51,286.14
| Facility | | $14,454.40 | $51,286.14 | $51,286.14 |