- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,454.71 / $6,456.54
| Facility | | $891.25 | $2,454.71 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $3,981.07 / $6,456.54
| Professional | | $616.60 | $3,981.07 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $7,943.28 / $13,489.63
| Facility | | $3,630.78 | $7,943.28 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,071.52 / $1,905.46
| Professional | | $758.58 | $1,071.52 | $1,905.46 |
- 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 / $87,096.36 / $87,096.36
| Professional | | $72,443.60 | $87,096.36 | $87,096.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,232.93 / $19,952.62
| Facility | | $6,456.54 | $10,232.93 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $933.25 / $1,949.84
| Professional | | $524.81 | $933.25 | $1,949.84 |