- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Facility | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $1,862.09
| Professional | | $891.25 | $1,230.27 | $1,862.09 |
- 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
- $2,398.83 / $2,398.83 / $3,162.28
| Professional | | $2,398.83 | $2,398.83 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $2,290.87
| Facility | | $1,621.81 | $1,621.81 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,174.90 / $1,621.81
| Professional | | $870.96 | $1,174.90 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $2,398.83 / $2,818.38
| Facility | | $776.25 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,288.25 / $1,659.59
| Professional | | $691.83 | $1,288.25 | $1,659.59 |