- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $812.83 / $1,445.44
| Professional | | $602.56 | $812.83 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,621.81 / $3,311.31
| Facility | | $1,348.96 | $1,621.81 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,258.93 / $1,348.96
| Professional | | $1,230.27 | $1,258.93 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $1,819.70
| Professional | | $741.31 | $741.31 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $741.31 / $851.14
| Professional | | $691.83 | $741.31 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,445.44 / $2,290.87
| Facility | | $549.54 | $1,445.44 | $2,290.87 |
- 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
- $426.58 / $630.96 / $1,318.26
| Facility | | $426.58 | $630.96 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $776.25 / $1,174.90
| Professional | | $549.54 | $776.25 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Facility | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $9,549.93 / $9,549.93
| Professional | | $7,244.36 | $9,549.93 | $9,549.93 |