- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $954.99 / $1,288.25
| Professional | | $812.83 | $954.99 | $1,288.25 |
- 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
- $1,659.59 / $1,659.59 / $2,187.76
| Professional | | $1,659.59 | $1,659.59 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,584.89
| Facility | | $1,202.26 | $1,202.26 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $891.25 / $1,202.26
| Professional | | $724.44 | $891.25 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,995.26 / $2,344.23
| Facility | | $851.14 | $1,995.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $870.96 / $1,174.90
| Professional | | $575.44 | $870.96 | $1,174.90 |