- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,294.26 / $1,294.26 / $1,294.26
| Facility | | $1,294.26 | $1,294.26 | $1,294.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.26 / $1,294.26 / $1,342.79
| Professional | | $1,294.26 | $1,294.26 | $1,342.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.03 / $1,213.36
| Facility | | $0.02 | $0.03 | $1,213.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.36 / $1,237.64 / $1,617.82
| Professional | | $1,213.36 | $1,237.64 | $1,617.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Facility | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Professional | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $649.04 / $1,485.60 / $6,076.00
| Facility | | $649.04 | $1,485.60 | $6,076.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.33 / $1,388.63 / $1,585.46
| Professional | | $1,180.33 | $1,388.63 | $1,585.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.33 / $1,388.63 / $1,606.64
| Professional | | $1,180.33 | $1,388.63 | $1,606.64 |