- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Facility | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,897.79 / $7,943.28
| Professional | | $4,265.80 | $4,897.79 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218,776.16 / $524,807.46 / $954,992.59
| Facility | | $218,776.16 | $524,807.46 | $954,992.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,912.51 / $8,912.51 / $11,748.98
| Professional | | $8,912.51 | $8,912.51 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $8,511.38
| Facility | | $6,606.93 | $6,606.93 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,897.79 / $6,606.93
| Professional | | $3,890.45 | $4,897.79 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $10,715.19 / $12,589.25
| Facility | | $6,025.60 | $10,715.19 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,897.79 / $7,079.46
| Professional | | $3,090.30 | $4,897.79 | $7,079.46 |