- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.22 / $1,822.43 / $2,981.77
| Professional | | $1,177.22 | $1,822.43 | $2,981.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,279.06 / $2,279.06 / $2,848.83
| Professional | | $2,279.06 | $2,279.06 | $2,848.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.92 / $257.92 / $3,352.96
| Facility | | $257.92 | $257.92 | $3,352.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.92 / $257.92 / $3,352.96
| Professional | | $257.92 | $257.92 | $3,352.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,406.76
| Facility | | $1,406.76 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.74 / $1,406.76 / $1,917.00
| Professional | | $229.74 | $1,406.76 | $1,917.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.90 / $2,476.12 / $2,476.12
| Professional | | $1,980.90 | $2,476.12 | $2,476.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.03 / $1,921.04 / $2,476.12
| Professional | | $1,808.03 | $1,921.04 | $2,476.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,406.76
| Facility | | $1,406.76 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.74 / $1,406.76 / $1,917.00
| Professional | | $229.74 | $1,406.76 | $1,917.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.77 / $1,561.52 / $2,171.51
| Professional | | $988.77 | $1,561.52 | $2,171.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.03 / $1,808.03 / $1,808.03
| Facility | | $1,808.03 | $1,808.03 | $1,808.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.03 / $1,808.03 / $2,476.12
| Professional | | $1,808.03 | $1,808.03 | $2,476.12 |