- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,068.46
| Facility | | $2,068.46 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,130.53
| Professional | | $2,068.46 | $2,068.46 | $2,130.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $4,238.10
| Facility | | $1.00 | $1.00 | $4,238.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.06 / $2,109.54 / $2,220.57
| Professional | | $176.06 | $2,109.54 | $2,220.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.27 / $494.83 / $695.52
| Facility | | $269.27 | $494.83 | $695.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.16 / $210.45 / $227.79
| Professional | | $181.16 | $210.45 | $227.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.15 / $453.48 / $626.76
| Facility | | $239.15 | $453.48 | $626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.36 / $179.36 / $191.32
| Professional | | $179.36 | $179.36 | $191.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,220.57 / $2,220.57 / $4,893.62
| Facility | | $2,220.57 | $2,220.57 | $4,893.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,220.57 / $2,220.57 / $5,093.77
| Professional | | $2,220.57 | $2,220.57 | $5,093.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $3,834.94
| Professional | | $2,068.46 | $2,068.46 | $3,834.94 |