- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Facility | | $8,709.64 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,918.31 / $11,220.18
| Professional | | $6,025.60 | $6,918.31 | $11,220.18 |
- 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
- $13,489.63 / $13,489.63 / $18,197.01
| Professional | | $13,489.63 | $13,489.63 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $12,882.50
| Facility | | $9,332.54 | $9,332.54 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,918.31 / $9,332.54
| Professional | | $6,025.60 | $6,918.31 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $16,595.87 / $19,498.45
| Facility | | $6,025.60 | $16,595.87 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,244.36 / $10,964.78
| Professional | | $4,786.30 | $7,244.36 | $10,964.78 |