- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,981.07 / $6,456.54
| Professional | | $3,467.37 | $3,981.07 | $6,456.54 |
- 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
- $7,244.36 / $7,244.36 / $9,772.37
| Professional | | $7,244.36 | $7,244.36 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $6,918.31
| Facility | | $4,786.30 | $4,786.30 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,073.80 / $4,786.30
| Professional | | $3,235.94 | $4,073.80 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $8,709.64 / $10,232.93
| Facility | | $5,011.87 | $8,709.64 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,168.69 / $5,888.44
| Professional | | $2,511.89 | $4,168.69 | $5,888.44 |