- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,122.02
| Facility | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $891.25 / $1,659.59
| Professional | | $776.25 | $891.25 | $1,659.59 |
- 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
- $1,737.80 / $1,737.80 / $2,290.87
| Professional | | $1,737.80 | $1,737.80 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,621.81
| Facility | | $1,174.90 | $1,174.90 | $1,621.81 |
- 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
- $741.31 / $2,137.96 / $2,511.89
| Facility | | $741.31 | $2,137.96 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $954.99 / $1,445.44
| Professional | | $616.60 | $954.99 | $1,445.44 |