- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,318.26 / $1,995.26
| Facility | | $645.65 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $1,698.24
| Professional | | $977.24 | $1,412.54 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,840.32 / $28,840.32 / $28,840.32
| Facility | | $28,840.32 | $28,840.32 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,479.11
| Professional | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $12,882.50 / $39,810.72
| Facility | | $11,748.98 | $12,882.50 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $42.66 / $50.12
| Professional | | $42.66 | $42.66 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $14,791.08 / $33,113.11
| Facility | | $1,819.70 | $14,791.08 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,698.24 / $2,951.21
| Professional | | $1,318.26 | $1,698.24 | $2,951.21 |