- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,897.79 / $6,456.54
| Professional | | $2,951.21 | $4,897.79 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,890.45 / $3,890.45
| Professional | | $3,311.31 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $9,772.37
| Facility | | $741.31 | $741.31 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $9,772.37
| Professional | | $741.31 | $741.31 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Facility | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $5,623.41 / $6,606.93
| Professional | | $660.69 | $5,623.41 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,370.32 / $5,370.32
| Professional | | $4,265.80 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $5,370.32
| Professional | | $4,570.88 | $4,570.88 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $660.69 / $4,466.84
| Facility | | $338.84 | $660.69 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,951.21 / $4,677.35
| Professional | | $1,659.59 | $2,951.21 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $5,370.32
| Facility | | $4,570.88 | $4,570.88 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $5,370.32
| Professional | | $4,570.88 | $4,570.88 | $5,370.32 |