- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,542.24
| Facility | | $1,494.41 | $1,494.41 | $1,542.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,569.13
| Professional | | $1,494.41 | $1,494.41 | $1,569.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,409.82 / $1,494.41 / $1,494.41
| Facility | | $1,409.82 | $1,494.41 | $1,494.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,494.41
| Professional | | $1,494.41 | $1,494.41 | $1,494.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,494.41
| Facility | | $1,494.41 | $1,494.41 | $1,494.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $747.21 / $1,494.41 / $1,494.41
| Professional | | $747.21 | $1,494.41 | $1,494.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $2,674.89 / $7,994.77
| Professional | | $40.00 | $2,674.89 | $7,994.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,509.35
| Professional | | $1,494.41 | $1,494.41 | $1,509.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,542.24 / $1,542.24
| Professional | | $1,494.41 | $1,542.24 | $1,542.24 |