- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.26 / $1,208.86 / $5,814.44
| Professional | | $886.26 | $1,208.86 | $5,814.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,335.63 / $1,335.63 / $1,335.63
| Facility | | $1,335.63 | $1,335.63 | $1,335.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.01 / $975.01 / $1,335.63
| Professional | | $975.01 | $975.01 | $1,335.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.66 / $3,906.90 / $5,095.58
| Professional | | $1,410.66 | $3,906.90 | $5,095.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.86 / $1,656.15 / $2,015.23
| Facility | | $1,208.86 | $1,656.15 | $2,015.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.40 / $1,894.32 / $2,115.98
| Professional | | $1,498.40 | $1,894.32 | $2,115.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,599.64 / $2,015.23 / $2,216.75
| Facility | | $1,599.64 | $2,015.23 | $2,216.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,813.71 / $2,015.23 / $2,087.32
| Professional | | $1,813.71 | $2,015.23 | $2,087.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.86 / $1,764.61 / $2,115.98
| Facility | | $1,208.86 | $1,764.61 | $2,115.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.01 / $1,764.61 / $2,216.75
| Professional | | $975.01 | $1,764.61 | $2,216.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,678.98 / $3,351.26 / $7,070.09
| Facility | | $1,678.98 | $3,351.26 | $7,070.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.10 / $2,216.75 / $2,216.75
| Professional | | $1,733.10 | $2,216.75 | $2,216.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.16 / $920.18 / $1,755.58
| Professional | | $866.16 | $920.18 | $1,755.58 |