- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,344.23 / $3,467.37
| Facility | | $1,230.27 | $2,344.23 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $2,398.83
| Professional | | $1,230.27 | $1,737.80 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131,825.67 / $131,825.67 / $181,970.09
| Facility | | $131,825.67 | $131,825.67 | $181,970.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,949.84
| Professional | | $1,479.11 | $1,479.11 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,073.80
| Facility | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $12,022.64 / $22,908.68
| Facility | | $3,715.35 | $12,022.64 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $3,630.78
| Professional | | $1,659.59 | $2,137.96 | $3,630.78 |