- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $645.65 / $1,047.13
| Professional | | $524.81 | $645.65 | $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
- $1,071.52 / $1,071.52 / $1,412.54
| Professional | | $1,071.52 | $1,071.52 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $1,000.00
| Facility | | $758.58 | $758.58 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $549.54 / $758.58
| Professional | | $512.86 | $549.54 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,412.54 / $1,659.59
| Facility | | $602.56 | $1,412.54 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $588.84 / $758.58
| Professional | | $398.11 | $588.84 | $758.58 |