- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.14 / $1,758.96 / $2,878.15
| Professional | | $1,136.14 | $1,758.96 | $2,878.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,199.53 / $2,199.53 / $2,749.41
| Professional | | $2,199.53 | $2,199.53 | $2,749.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.95 / $248.95 / $3,236.35
| Facility | | $248.95 | $248.95 | $3,236.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.95 / $248.95 / $3,236.35
| Professional | | $248.95 | $248.95 | $3,236.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.64 / $1,219.64 / $1,219.64
| Facility | | $1,219.64 | $1,219.64 | $1,219.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.74 / $1,219.64 / $1,944.00
| Professional | | $221.74 | $1,219.64 | $1,944.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.73 / $1,744.94 / $1,854.00
| Professional | | $1,710.73 | $1,744.94 | $1,854.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,587.83 / $2,587.83 / $2,587.83
| Professional | | $2,587.83 | $2,587.83 | $2,587.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.64 / $1,219.64 / $1,219.64
| Facility | | $1,219.64 | $1,219.64 | $1,219.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.74 / $1,219.64 / $1,944.00
| Professional | | $221.74 | $1,219.64 | $1,944.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.86 / $1,513.35 / $1,991.28
| Professional | | $1,017.86 | $1,513.35 | $1,991.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,744.94 / $1,744.94 / $1,744.94
| Facility | | $1,744.94 | $1,744.94 | $1,744.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.94 / $1,744.94 / $1,854.00
| Professional | | $1,744.94 | $1,744.94 | $1,854.00 |