- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $776.25 / $1,047.13
| Professional | | $660.69 | $776.25 | $1,047.13 |
- 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
- $1,412.54 / $1,412.54 / $1,862.09
| Professional | | $1,412.54 | $1,412.54 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $1,318.26
| Facility | | $851.14 | $851.14 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $630.96 / $851.14
| Professional | | $575.44 | $630.96 | $851.14 |
- 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 / $724.44 / $977.24
| Professional | | $457.09 | $724.44 | $977.24 |