- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $10,471.29
| Facility | | $10,471.29 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $37,153.52
| Professional | | $630.96 | $630.96 | $37,153.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64,565.42 / $83,176.38 / $95,499.26
| Facility | | $64,565.42 | $83,176.38 | $95,499.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $263.03 / $263.03
| Professional | | $263.03 | $263.03 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $46,773.51
| Facility | | $630.96 | $630.96 | $46,773.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $79.43 / $85.11
| Professional | | $60.26 | $79.43 | $85.11 |