- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $851.14 / $1,318.26
| Professional | | $645.65 | $851.14 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,238.72 / $3,019.95
| Facility | | $1,412.54 | $2,238.72 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,148.15 / $1,230.27
| Professional | | $1,122.02 | $1,148.15 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $1,047.13 / $1,047.13
| Facility | | $257.04 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $1,737.80
| Professional | | $758.58 | $758.58 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $758.58 / $977.24
| Professional | | $707.95 | $758.58 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,318.26 / $2,187.76
| Facility | | $645.65 | $1,318.26 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $660.69 / $1,202.26
| Facility | | $457.09 | $660.69 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $724.44 / $1,071.52
| Professional | | $562.34 | $724.44 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Facility | | $7,079.46 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $10,964.78
| Professional | | $7,585.78 | $7,585.78 | $10,964.78 |