- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,918.31
| Facility | | $4,897.79 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $2,290.87
| Professional | | $1,258.93 | $1,778.28 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218,776.16 / $218,776.16 / $218,776.16
| Facility | | $218,776.16 | $218,776.16 | $218,776.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29,512.09 / $218,776.16 / $218,776.16
| Professional | | $29,512.09 | $218,776.16 | $218,776.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,623.41 / $6,918.31
| Facility | | $2,238.72 | $5,623.41 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $1,862.09 / $2,754.23
| Professional | | $100.00 | $1,862.09 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $15,488.17 / $25,118.86
| Facility | | $2,187.76 | $15,488.17 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,137.96 / $2,884.03
| Professional | | $1,819.70 | $2,137.96 | $2,884.03 |