- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.14 / $1,146.32 / $5,996.89
| Professional | | $785.14 | $1,146.32 | $5,996.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.41 / $1,108.41 / $1,108.41
| Facility | | $1,108.41 | $1,108.41 | $1,108.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.14 / $809.14 / $1,108.41
| Professional | | $809.14 | $809.14 | $1,108.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.68 / $3,700.23 / $4,826.01
| Professional | | $1,337.68 | $3,700.23 | $4,826.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,146.32 / $1,570.46 / $1,910.97
| Facility | | $1,146.32 | $1,570.46 | $1,910.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.81 / $1,796.31 / $2,006.52
| Professional | | $1,406.81 | $1,796.31 | $2,006.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,516.89 / $1,910.97 / $2,229.01
| Facility | | $1,516.89 | $1,910.97 | $2,229.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.87 / $1,910.97 / $2,229.01
| Professional | | $1,719.87 | $1,910.97 | $2,229.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.41 / $1,639.24 / $2,006.52
| Facility | | $1,108.41 | $1,639.24 | $2,006.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.14 / $1,673.31 / $2,102.07
| Professional | | $809.14 | $1,673.31 | $2,102.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,592.11 / $3,177.86 / $6,704.28
| Facility | | $1,592.11 | $3,177.86 | $6,704.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,643.43 / $2,102.07 / $2,102.07
| Professional | | $1,643.43 | $2,102.07 | $2,102.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.40 / $871.57 / $1,662.85
| Professional | | $820.40 | $871.57 | $1,662.85 |