- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,805.02 / $1,805.02 / $1,805.02
| Facility | | $1,805.02 | $1,805.02 | $1,805.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,657.34 / $1,805.02
| Professional | | $1,640.93 | $1,657.34 | $1,805.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $259.77 / $613.74 / $1,517.79
| Facility | | $259.77 | $613.74 | $1,517.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.83 / $324.73 / $767.17
| Professional | | $263.83 | $324.73 | $767.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.05 / $1,640.93 / $1,640.93
| Facility | | $1,548.05 | $1,640.93 | $1,640.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Professional | | $1,640.93 | $1,640.93 | $1,640.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,599.91 / $1,805.02 / $3,664.19
| Facility | | $1,599.91 | $1,805.02 | $3,664.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $3,560.82
| Professional | | $1,640.93 | $1,640.93 | $3,560.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Professional | | $1,640.93 | $1,640.93 | $1,640.93 |