- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $976.55 / $995.70 / $1,014.85
| Facility | | $976.55 | $995.70 | $1,014.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.11 / $1,014.85 / $1,646.74
| Professional | | $919.11 | $1,014.85 | $1,646.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.07 / $1,302.07 / $1,302.07
| Professional | | $1,302.07 | $1,302.07 | $1,302.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,186.77 / $2,186.77 / $2,186.77
| Facility | | $2,186.77 | $2,186.77 | $2,186.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,540.39 / $1,540.39 / $1,540.39
| Facility | | $1,540.39 | $1,540.39 | $1,540.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.48 / $1,124.48 / $1,540.39
| Professional | | $1,124.48 | $1,124.48 | $1,540.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,654.22 / $10,128.96 / $10,128.96
| Facility | | $3,654.22 | $10,128.96 | $10,128.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,951.02 / $10,951.02 / $15,922.50
| Professional | | $10,951.02 | $10,951.02 | $15,922.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $625.83 / $1,641.72 / $2,186.77
| Facility | | $625.83 | $1,641.72 | $2,186.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.83 / $1,968.09 / $2,186.77
| Professional | | $625.83 | $1,968.09 | $2,186.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,672.88 / $2,186.77 / $4,920.22
| Professional | | $1,672.88 | $2,186.77 | $4,920.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $625.83 / $1,540.39 / $2,186.77
| Facility | | $625.83 | $1,540.39 | $2,186.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.48 / $1,124.48 / $1,586.60
| Professional | | $1,124.48 | $1,124.48 | $1,586.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.83 / $1,168.21 / $1,390.73
| Professional | | $807.83 | $1,168.21 | $1,390.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.16 / $1,181.67 / $2,186.77
| Professional | | $1,164.16 | $1,181.67 | $2,186.77 |