- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $954.99 / $1,258.93
| Professional | | $660.69 | $954.99 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,290.87 / $3,090.30
| Facility | | $1,445.44 | $2,290.87 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,174.90 / $1,288.25
| Professional | | $1,148.15 | $1,174.90 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $912.01 / $954.99
| Facility | | $676.08 | $912.01 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $1,174.90
| Professional | | $660.69 | $660.69 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $912.01 / $977.24
| Professional | | $851.14 | $912.01 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,288.25 / $2,238.72
| Facility | | $660.69 | $1,288.25 | $2,238.72 |
- 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
- $602.56 / $1,096.48 / $1,230.27
| Facility | | $602.56 | $1,096.48 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $758.58 / $1,122.02
| Professional | | $602.56 | $758.58 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $7,762.47 / $7,762.47
| Facility | | $7,762.47 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $13,803.84
| Professional | | $9,120.11 | $9,120.11 | $13,803.84 |