- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,951.21 / $3,890.45
| Professional | | $2,187.76 | $2,951.21 | $3,890.45 |
- 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
- $4,677.35 / $4,677.35 / $6,165.95
| Professional | | $4,677.35 | $4,677.35 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $389.05
| Professional | | $251.19 | $251.19 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $363.08 / $3,467.37
| Facility | | $263.03 | $363.08 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $257.04 / $2,884.03
| Professional | | $151.36 | $257.04 | $2,884.03 |