- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,570.40 / $3,630.78
| Professional | | $1,230.27 | $2,570.40 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,467.37
| Professional | | $2,691.53 | $2,691.53 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $4,786.30
| Facility | | $363.08 | $363.08 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $4,786.30
| Professional | | $363.08 | $363.08 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $2,238.72 / $2,290.87
| Professional | | $346.74 | $2,238.72 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,754.23
| Professional | | $2,570.40 | $2,570.40 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $660.69 / $2,187.76
| Facility | | $151.36 | $660.69 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,698.24 / $2,818.38
| Professional | | $1,047.13 | $1,698.24 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,570.40
| Facility | | $2,511.89 | $2,511.89 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,570.40 / $2,754.23
| Professional | | $2,511.89 | $2,570.40 | $2,754.23 |