- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $977.24 / $1,778.28
| Professional | | $851.14 | $977.24 | $1,778.28 |
- 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
- $1,778.28 / $1,778.28 / $2,344.23
| Professional | | $1,778.28 | $1,778.28 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,659.59
| Facility | | $1,380.38 | $1,380.38 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,000.00 / $1,380.38
| Professional | | $870.96 | $1,000.00 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,344.23 / $2,754.23
| Facility | | $794.33 | $2,344.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,023.29 / $1,584.89
| Professional | | $676.08 | $1,023.29 | $1,584.89 |