- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.07 / $792.88 / $4,104.97
| Professional | | $704.07 | $792.88 | $4,104.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,014.49 / $1,014.49 / $1,014.49
| Facility | | $1,014.49 | $1,014.49 | $1,014.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.58 / $740.58 / $1,014.49
| Professional | | $740.58 | $740.58 | $1,014.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.23 / $2,676.09 / $3,490.28
| Professional | | $925.23 | $2,676.09 | $3,490.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $792.88 / $1,086.25 / $1,321.76
| Facility | | $792.88 | $1,086.25 | $1,321.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.78 / $1,242.45 / $1,387.85
| Professional | | $982.78 | $1,242.45 | $1,387.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,049.19 / $1,263.33 / $1,389.66
| Facility | | $1,049.19 | $1,263.33 | $1,389.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.03 / $1,263.33 / $1,321.76
| Professional | | $1,050.03 | $1,263.33 | $1,321.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $792.88 / $1,135.21 / $1,387.85
| Facility | | $792.88 | $1,135.21 | $1,387.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.58 / $1,157.38 / $1,453.94
| Professional | | $740.58 | $1,157.38 | $1,453.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,101.22 / $2,198.04 / $4,637.16
| Facility | | $1,101.22 | $2,198.04 | $4,637.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.71 / $1,453.94 / $1,453.94
| Professional | | $1,136.71 | $1,453.94 | $1,453.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.27 / $630.26 / $1,202.46
| Professional | | $593.27 | $630.26 | $1,202.46 |