- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $12,589.25 / $12,589.25
| Facility | | $12,589.25 | $12,589.25 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $9,772.37 / $13,489.63
| Professional | | $7,244.36 | $9,772.37 | $13,489.63 |
- 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
- $19,498.45 / $19,498.45 / $25,703.96
| Professional | | $19,498.45 | $19,498.45 | $25,703.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $18,620.87
| Facility | | $11,748.98 | $11,748.98 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $8,511.38 / $11,748.98
| Professional | | $7,244.36 | $8,511.38 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $19,498.45 / $22,908.68
| Facility | | $7,585.78 | $19,498.45 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $10,471.29 / $13,182.57
| Professional | | $5,623.41 | $10,471.29 | $13,182.57 |