- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.56 / $3,155.08 / $4,174.60
| Professional | | $1,830.56 | $3,155.08 | $4,174.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,676.92 / $2,230.86 / $2,257.07
| Professional | | $1,676.92 | $2,230.86 | $2,257.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $462.65 / $462.65 / $6,014.45
| Facility | | $462.65 | $462.65 | $6,014.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.65 / $462.65 / $6,014.45
| Professional | | $462.65 | $462.65 | $6,014.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,446.40
| Facility | | $2,446.40 | $2,446.40 | $2,446.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.08 / $2,446.40 / $3,210.83
| Professional | | $321.08 | $2,446.40 | $3,210.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,229.98 / $4,037.48 / $4,037.48
| Professional | | $3,229.98 | $4,037.48 | $4,037.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,465.84 / $3,465.84 / $4,037.48
| Professional | | $3,465.84 | $3,465.84 | $4,037.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,446.40
| Facility | | $2,446.40 | $2,446.40 | $2,446.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.08 / $2,446.40 / $3,331.31
| Professional | | $321.08 | $2,446.40 | $3,331.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.75 / $2,127.44 / $3,082.27
| Professional | | $1,383.75 | $2,127.44 | $3,082.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,465.84 / $3,465.84 / $3,465.84
| Facility | | $3,465.84 | $3,465.84 | $3,465.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,465.84 / $3,465.84 / $4,037.48
| Professional | | $3,465.84 | $3,465.84 | $4,037.48 |