- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $812.83 / $1,122.02
| Professional | | $616.60 | $812.83 | $1,122.02 |
- 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
- $1,174.90 / $1,174.90 / $1,584.89
| Professional | | $1,174.90 | $1,174.90 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $1,122.02
| Facility | | $891.25 | $891.25 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $645.65 / $891.25
| Professional | | $575.44 | $645.65 | $891.25 |
- 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 / $660.69 / $891.25
| Professional | | $457.09 | $660.69 | $891.25 |