- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.73 / $1,427.45 / $1,427.45
| Facility | | $1,370.73 | $1,427.45 | $1,427.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,470.27
| Professional | | $1,427.45 | $1,427.45 | $1,470.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,427.45
| Professional | | $1,427.45 | $1,427.45 | $1,427.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $49.63 / $1,346.65 / $1,427.45
| Facility | | $49.63 | $1,346.65 | $1,427.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,427.45
| Professional | | $1,427.45 | $1,427.45 | $1,427.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.73 / $1,513.10 / $2,352.87
| Facility | | $1,370.73 | $1,513.10 | $2,352.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.92 / $1,570.20 / $2,026.98
| Professional | | $1,555.92 | $1,570.20 | $2,026.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,288.69 / $2,288.69 / $2,288.69
| Facility | | $2,288.69 | $2,288.69 | $2,288.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,427.45
| Professional | | $1,427.45 | $1,427.45 | $1,427.45 |