- 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
- $923.88 / $1,014.85 / $1,646.74
| Professional | | $923.88 | $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
- $1,407.05 / $1,407.05 / $1,407.05
| Facility | | $1,407.05 | $1,407.05 | $1,407.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.15 / $1,027.15 / $1,027.15
| Professional | | $1,027.15 | $1,027.15 | $1,027.15 |
- 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 / $2,011.83 / $2,186.77
| Professional | | $625.83 | $2,011.83 | $2,186.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $625.83 / $1,407.05 / $2,186.77
| Facility | | $625.83 | $1,407.05 | $2,186.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.15 / $1,027.15 / $1,765.23
| Professional | | $1,027.15 | $1,027.15 | $1,765.23 |
- 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 / $1,183.49 / $2,186.77
| Professional | | $1,164.16 | $1,183.49 | $2,186.77 |