- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,737.80
| Facility | | $1,202.26 | $1,202.26 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $616.60 / $1,288.25
| Professional | | $446.68 | $616.60 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,318.26 / $2,398.83
| Facility | | $660.69 | $1,318.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $575.44 / $676.08
| Professional | | $562.34 | $575.44 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $758.58 / $954.99
| Professional | | $630.96 | $758.58 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $870.96
| Facility | | $660.69 | $660.69 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $691.83 / $794.33
| Professional | | $645.65 | $691.83 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,318.26 / $2,398.83
| Facility | | $1,000.00 | $1,318.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $691.83
| Professional | | $562.34 | $562.34 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $794.33
| Professional | | $275.42 | $275.42 | $794.33 |