- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $776.25 / $1,023.29
| Professional | | $549.54 | $776.25 | $1,023.29 |
- 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
- $1,584.89 / $1,584.89 / $2,089.30
| Professional | | $1,584.89 | $1,584.89 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $1,479.11
| Facility | | $977.24 | $977.24 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $707.95 / $977.24
| Professional | | $575.44 | $707.95 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,584.89 / $1,862.09
| Facility | | $676.08 | $1,584.89 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $741.31 / $1,047.13
| Professional | | $457.09 | $741.31 | $1,047.13 |