- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.40 / $1,593.20 / $2,587.64
| Professional | | $933.40 | $1,593.20 | $2,587.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.40 / $2,100.40 / $2,625.50
| Professional | | $2,100.40 | $2,100.40 | $2,625.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.14 / $228.14 / $2,965.82
| Facility | | $228.14 | $228.14 | $2,965.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.14 / $228.14 / $2,965.82
| Professional | | $228.14 | $228.14 | $2,965.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $1,377.00
| Facility | | $1,350.00 | $1,350.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.50 / $1,350.00 / $1,833.30
| Professional | | $1,147.50 | $1,350.00 | $1,833.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.36 / $1,933.27 / $2,054.10
| Professional | | $1,895.36 | $1,933.27 | $2,054.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.60 / $2,769.60 / $2,769.60
| Professional | | $2,769.60 | $2,769.60 | $2,769.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $1,377.00
| Facility | | $1,350.00 | $1,350.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.50 / $1,350.00 / $1,833.30
| Professional | | $1,147.50 | $1,350.00 | $1,833.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.93 / $1,538.34 / $2,322.30
| Professional | | $897.93 | $1,538.34 | $2,322.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,933.27 / $1,933.27 / $1,933.27
| Facility | | $1,933.27 | $1,933.27 | $1,933.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,933.27 / $1,933.27 / $2,054.10
| Professional | | $1,933.27 | $1,933.27 | $2,054.10 |