- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.09 / $1,306.28 / $1,657.43
| Professional | | $1,080.09 | $1,306.28 | $1,657.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.03 / $1,920.23 / $2,400.29
| Professional | | $240.03 | $1,920.23 | $2,400.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,772.06 / $2,111.63
| Facility | | $1,772.06 | $1,772.06 | $2,111.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.25 / $1,772.06 / $3,539.06
| Professional | | $1,506.25 | $1,772.06 | $3,539.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,208.27 / $2,208.27 / $2,400.29
| Professional | | $2,208.27 | $2,208.27 | $2,400.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.50 / $1,323.86 / $1,942.86
| Professional | | $1,059.50 | $1,323.86 | $1,942.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,772.06 / $2,111.63
| Facility | | $1,772.06 | $1,772.06 | $2,111.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.25 / $1,772.06 / $3,539.06
| Professional | | $1,506.25 | $1,772.06 | $3,539.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,030.79 / $2,372.76 / $2,428.57
| Professional | | $2,030.79 | $2,372.76 | $2,428.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.53 / $988.27 / $1,791.25
| Facility | | $109.53 | $988.27 | $1,791.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.05 / $1,364.31 / $2,552.31
| Professional | | $928.05 | $1,364.31 | $2,552.31 |