- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $6,456.54 / $8,912.51
| Professional | | $3,388.44 | $6,456.54 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,495.41 / $7,244.36
| Professional | | $5,248.07 | $5,495.41 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $12,022.64
| Facility | | $912.01 | $912.01 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $12,022.64
| Professional | | $912.01 | $912.01 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $3,715.35 / $6,025.60
| Professional | | $812.83 | $3,715.35 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,165.95 / $6,165.95
| Professional | | $4,897.79 | $6,165.95 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $6,165.95
| Facility | | $6,165.95 | $6,165.95 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $6,165.95
| Professional | | $5,370.32 | $5,370.32 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $741.31 / $4,677.35
| Facility | | $371.54 | $741.31 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,715.35 / $6,165.95
| Professional | | $2,454.71 | $3,715.35 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,370.32 / $6,165.95
| Facility | | $5,248.07 | $5,370.32 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $6,165.95
| Professional | | $5,370.32 | $5,370.32 | $6,165.95 |