- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $794.33 / $1,318.26
| Professional | | $645.65 | $794.33 | $1,318.26 |
- 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
- $1,584.89 / $1,584.89 / $2,089.30
| Professional | | $1,584.89 | $1,584.89 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $1,513.56
| Facility | | $912.01 | $912.01 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $660.69 / $912.01
| Professional | | $616.60 | $660.69 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,698.24 / $1,995.26
| Facility | | $630.96 | $1,698.24 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $851.14 / $1,122.02
| Professional | | $489.78 | $851.14 | $1,122.02 |