- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,165.95 / $9,549.93
| Professional | | $5,370.32 | $6,165.95 | $9,549.93 |
- 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
- $11,481.54 / $11,481.54 / $15,135.61
| Professional | | $11,481.54 | $11,481.54 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $10,964.78
| Facility | | $9,120.11 | $9,120.11 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,606.93 / $9,120.11
| Professional | | $5,128.61 | $6,606.93 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $14,125.38 / $16,595.87
| Facility | | $5,128.61 | $14,125.38 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,309.57 / $9,332.54
| Professional | | $4,073.80 | $6,309.57 | $9,332.54 |