- 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
- $1,494.41 / $1,494.41 / $1,554.19
| Professional | | $1,494.41 | $1,494.41 | $1,554.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $1,542.24 / $3,492.82
| Facility | | $1.00 | $1,542.24 | $3,492.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.79 / $1,495.97 / $1,542.24
| Professional | | $1,233.79 | $1,495.97 | $1,542.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,422.53 / $4,451.77 / $6,257.35
| Facility | | $2,422.53 | $4,451.77 | $6,257.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.76 / $1,876.15 / $1,933.62
| Professional | | $1,537.76 | $1,876.15 | $1,933.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,151.55 / $4,079.77 / $5,638.78
| Facility | | $2,151.55 | $4,079.77 | $5,638.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.54 / $1,522.54 / $1,721.24
| Professional | | $1,522.54 | $1,522.54 | $1,721.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.31 / $1,542.24 / $3,398.81
| Facility | | $1,350.31 | $1,542.24 | $3,398.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,542.24 / $1,542.24 / $3,537.74
| Professional | | $1,542.24 | $1,542.24 | $3,537.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $2,770.64
| Professional | | $1,494.41 | $1,494.41 | $2,770.64 |