- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,041.74 / $2,818.38
| Professional | | $1,380.38 | $2,041.74 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,162.28 / $4,897.79
| Facility | | $2,398.83 | $3,162.28 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,801.89 / $3,801.89
| Professional | | $3,548.13 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,041.74
| Facility | | $1,737.80 | $1,737.80 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,737.80
| Professional | | $1,258.93 | $1,258.93 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,691.53 / $3,467.37
| Facility | | $891.25 | $2,691.53 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,235.94 / $3,388.44
| Professional | | $2,691.53 | $3,235.94 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $2,884.03
| Professional | | $30.20 | $30.20 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,311.31 / $3,311.31
| Facility | | $3,162.28 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,801.89
| Professional | | $2,398.83 | $2,398.83 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,388.44 / $3,388.44
| Professional | | $2,691.53 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,819.70 / $2,089.30
| Facility | | $1,445.44 | $1,819.70 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,380.38 / $2,137.96
| Professional | | $1,288.25 | $1,380.38 | $2,137.96 |