- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,754.23 / $4,570.88
| Professional | | $2,290.87 | $2,754.23 | $4,570.88 |
- 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
- $4,897.79 / $4,897.79 / $6,606.93
| Professional | | $4,897.79 | $4,897.79 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $4,677.35
| Facility | | $3,715.35 | $3,715.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,715.35
| Professional | | $2,691.53 | $2,691.53 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,888.44 / $6,918.31
| Facility | | $3,388.44 | $5,888.44 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,754.23 / $3,981.07
| Professional | | $1,698.24 | $2,754.23 | $3,981.07 |