- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Facility | | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $977.24 / $1,584.89
| Professional | | $776.25 | $977.24 | $1,584.89 |
- 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
- $1,513.56 / $1,513.56 / $1,995.26
| Professional | | $1,513.56 | $1,513.56 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,513.56 / $1,513.56
| Facility | | $1,445.44 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,096.48 / $1,513.56
| Professional | | $741.31 | $1,096.48 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,041.74 / $2,398.83
| Facility | | $1,148.15 | $2,041.74 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $870.96 / $1,348.96
| Professional | | $588.84 | $870.96 | $1,348.96 |