- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,011.87 / $7,943.28
| Professional | | $4,073.80 | $5,011.87 | $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
- $7,943.28 / $7,943.28 / $10,715.19
| Professional | | $7,943.28 | $7,943.28 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,585.78
| Facility | | $7,244.36 | $7,244.36 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,248.07 / $7,244.36
| Professional | | $3,890.45 | $5,248.07 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $10,715.19 / $12,589.25
| Facility | | $4,365.16 | $10,715.19 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,570.88 / $7,079.46
| Professional | | $3,090.30 | $4,570.88 | $7,079.46 |