- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $9,772.37
| Facility | | $9,772.37 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $8,317.64 / $13,489.63
| Professional | | $7,413.10 | $8,317.64 | $13,489.63 |
- 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
- $15,135.61 / $15,135.61 / $19,952.62
| Professional | | $15,135.61 | $15,135.61 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $14,454.40
| Facility | | $9,772.37 | $9,772.37 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $9,772.37
| Professional | | $8,317.64 | $8,317.64 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $18,197.01 / $21,379.62
| Facility | | $10,471.29 | $18,197.01 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $8,709.64 / $12,302.69
| Professional | | $5,248.07 | $8,709.64 | $12,302.69 |