- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Facility | | $1,237.28 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,274.40
| Professional | | $1,237.28 | $1,237.28 | $1,274.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $1,739.42
| Facility | | $1.00 | $1.00 | $1,739.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.35 / $1,154.73 / $1,190.44
| Professional | | $952.35 | $1,154.73 | $1,190.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,004.47 / $3,683.52 / $5,177.50
| Facility | | $2,004.47 | $3,683.52 | $5,177.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.67 / $1,344.89 / $1,552.38
| Professional | | $1,086.67 | $1,344.89 | $1,552.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,780.25 / $3,375.71 / $4,665.68
| Facility | | $1,780.25 | $3,375.71 | $4,665.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.91 / $1,075.91 / $1,424.20
| Professional | | $1,075.91 | $1,075.91 | $1,424.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.56 / $106.56 / $2,142.79
| Facility | | $106.56 | $106.56 | $2,142.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.44 / $1,190.44 / $2,730.75
| Professional | | $1,190.44 | $1,190.44 | $2,730.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $2,440.83
| Professional | | $1,237.28 | $1,237.28 | $2,440.83 |