- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,481.54 / $11,481.54 / $11,481.54
| Facility | | $11,481.54 | $11,481.54 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,709.64 / $10,000.00 / $16,595.87
| Professional | | $8,709.64 | $10,000.00 | $16,595.87 |
- 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
- $18,197.01 / $18,197.01 / $23,988.33
| Professional | | $18,197.01 | $18,197.01 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $12,882.50 / $16,982.44
| Facility | | $12,882.50 | $12,882.50 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,943.28 / $9,332.54 / $12,882.50
| Professional | | $7,943.28 | $9,332.54 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $21,877.62 / $25,703.96
| Facility | | $12,302.69 | $21,877.62 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $10,232.93 / $14,454.40
| Professional | | $6,309.57 | $10,232.93 | $14,454.40 |