- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,128.61 / $8,317.64
| Professional | | $4,365.16 | $5,128.61 | $8,317.64 |
- 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
- $10,232.93 / $10,232.93 / $13,489.63
| Professional | | $10,232.93 | $10,232.93 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $9,549.93
| Facility | | $8,128.31 | $8,128.31 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,888.44 / $8,128.31
| Professional | | $4,466.84 | $5,888.44 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $12,302.69 / $14,454.40
| Facility | | $4,466.84 | $12,302.69 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,623.41 / $8,128.31
| Professional | | $3,467.37 | $5,623.41 | $8,128.31 |