- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,511.89 / $3,801.89
| Professional | | $1,737.80 | $2,511.89 | $3,801.89 |
- 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
- $4,265.80 / $4,265.80 / $5,623.41
| Professional | | $4,265.80 | $4,265.80 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $4,073.80
| Facility | | $3,235.94 | $3,235.94 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $3,235.94
| Professional | | $1,778.28 | $2,398.83 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,897.79 / $5,754.40
| Facility | | $1,995.26 | $4,897.79 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,344.23 / $3,235.94
| Professional | | $1,412.54 | $2,344.23 | $3,235.94 |