- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,085.11 / $1,085.11 / $2,600.00
| Facility | | $1,085.11 | $1,085.11 | $2,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.10 / $1,085.11 / $1,085.11
| Professional | | $1,085.10 | $1,085.11 | $1,085.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $82,011.67 / $82,011.67 / $82,011.67
| Facility | | $82,011.67 | $82,011.67 | $82,011.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72,899.27 / $72,899.27 / $72,899.27
| Professional | | $72,899.27 | $72,899.27 | $72,899.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,562.26 / $3,562.26 / $3,562.26
| Professional | | $3,562.26 | $3,562.26 | $3,562.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,729.52 / $26,729.52 / $47,185.47
| Facility | | $26,729.52 | $26,729.52 | $47,185.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,357.60 / $16,357.60 / $16,357.60
| Facility | | $16,357.60 | $16,357.60 | $16,357.60 |