- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.78 / $1,527.88 / $2,499.86
| Professional | | $731.78 | $1,527.88 | $2,499.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.52 / $1,910.52 / $2,388.15
| Professional | | $1,910.52 | $1,910.52 | $2,388.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $216.23 / $216.23 / $2,810.99
| Facility | | $216.23 | $216.23 | $2,810.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.23 / $216.23 / $2,810.99
| Professional | | $216.23 | $216.23 | $2,810.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.60 / $1,436.52 / $1,436.52
| Facility | | $192.60 | $1,436.52 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.60 / $1,221.04 / $3,007.50
| Professional | | $192.60 | $1,221.04 | $3,007.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.94 / $1,515.66 / $1,610.40
| Professional | | $1,485.94 | $1,515.66 | $1,610.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,247.71 / $2,247.71 / $2,247.71
| Professional | | $2,247.71 | $2,247.71 | $2,247.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.60 / $1,436.52 / $1,436.52
| Facility | | $192.60 | $1,436.52 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.60 / $1,221.04 / $3,007.50
| Professional | | $192.60 | $1,221.04 | $3,007.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.14 / $1,309.09 / $1,806.26
| Professional | | $884.14 | $1,309.09 | $1,806.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,515.66 / $1,515.66 / $1,515.66
| Facility | | $1,515.66 | $1,515.66 | $1,515.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.66 / $1,515.66 / $1,610.40
| Professional | | $1,515.66 | $1,515.66 | $1,610.40 |