- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,318.26 / $1,995.26
| Professional | | $954.99 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,089.30 / $3,162.28
| Facility | | $1,698.24 | $2,089.30 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,398.83 / $2,398.83
| Professional | | $2,290.87 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,584.89 / $1,584.89
| Facility | | $1,348.96 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,584.89
| Professional | | $1,148.15 | $1,148.15 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,819.70 / $2,398.83
| Facility | | $602.56 | $1,819.70 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,089.30 / $2,187.76
| Professional | | $1,819.70 | $2,089.30 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $1,862.09
| Professional | | $30.20 | $30.20 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,089.30 / $2,089.30
| Facility | | $2,041.74 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,621.81 / $2,398.83
| Professional | | $1,548.82 | $1,621.81 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,187.76 / $2,290.87
| Professional | | $1,698.24 | $2,187.76 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,230.27 / $1,412.54
| Facility | | $794.33 | $1,230.27 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $933.25 / $1,445.44
| Professional | | $870.96 | $933.25 | $1,445.44 |