- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Facility | | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,623.41 / $9,332.54
| Professional | | $5,011.87 | $5,623.41 | $9,332.54 |
- 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
- $10,715.19 / $10,715.19 / $14,454.40
| Professional | | $10,715.19 | $10,715.19 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $10,232.93
| Facility | | $8,128.31 | $8,128.31 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,888.44 / $8,128.31
| Professional | | $5,011.87 | $5,888.44 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $13,803.84 / $16,218.10
| Facility | | $5,011.87 | $13,803.84 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,025.60 / $9,120.11
| Professional | | $3,981.07 | $6,025.60 | $9,120.11 |