- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,606.75 / $11,606.75 / $11,606.75
| Facility | | $11,606.75 | $11,606.75 | $11,606.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.82 / $1,123.24 / $1,136.16
| Professional | | $717.82 | $1,123.24 | $1,136.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39,671.44 / $51,449.63 / $58,015.97
| Facility | | $39,671.44 | $51,449.63 | $58,015.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.86 / $987.09 / $1,452.93
| Professional | | $799.86 | $987.09 | $1,452.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.80 / $1,174.22 / $1,628.55
| Professional | | $958.80 | $1,174.22 | $1,628.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.51 / $942.29 / $1,466.20
| Professional | | $846.51 | $942.29 | $1,466.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,606.75 / $11,606.75 / $11,606.75
| Facility | | $11,606.75 | $11,606.75 | $11,606.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.82 / $1,087.61 / $1,136.16
| Professional | | $717.82 | $1,087.61 | $1,136.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.16 / $1,100.45 / $1,466.20
| Professional | | $865.16 | $1,100.45 | $1,466.20 |