- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,000.00 / $1,380.38
| Professional | | $794.33 | $1,000.00 | $1,380.38 |
- 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
- $1,621.81 / $1,621.81 / $2,137.96
| Professional | | $1,621.81 | $1,621.81 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,548.82
| Facility | | $1,174.90 | $1,174.90 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $851.14 / $1,174.90
| Professional | | $794.33 | $851.14 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,187.76 / $2,570.40
| Facility | | $933.25 | $2,187.76 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $891.25 / $1,174.90
| Professional | | $630.96 | $891.25 | $1,174.90 |