- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $2,041.74 / $3,311.31
| Facility | | $912.01 | $2,041.74 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $602.56 / $870.96
| Professional | | $446.68 | $602.56 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $588.84
| Professional | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,202.26 / $2,570.40
| Facility | | $724.44 | $1,202.26 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Professional | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,023.29 / $1,621.81
| Professional | | $794.33 | $1,023.29 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,258.93 / $1,905.46
| Professional | | $812.83 | $1,258.93 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,905.46 / $3,162.28
| Facility | | $870.96 | $1,905.46 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $616.60 / $2,187.76
| Professional | | $446.68 | $616.60 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $831.76 / $1,122.02
| Facility | | $758.58 | $831.76 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $831.76 / $1,122.02
| Professional | | $758.58 | $831.76 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $891.25
| Facility | | $758.58 | $758.58 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $446.68 / $933.25
| Professional | | $316.23 | $446.68 | $933.25 |