- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,172.56
| Facility | | $1,172.56 | $1,172.56 | $1,172.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,207.73
| Professional | | $1,172.56 | $1,172.56 | $1,207.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.97 / $1.00 / $1,165.39
| Facility | | $0.97 | $1.00 | $1,165.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.19 / $1,107.11 / $1,165.39
| Professional | | $96.19 | $1,107.11 | $1,165.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,588.94 / $2,919.91 / $4,104.20
| Facility | | $1,588.94 | $2,919.91 | $4,104.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.98 / $1,230.57 / $1,344.17
| Professional | | $1,068.98 | $1,230.57 | $1,344.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,411.20 / $2,675.92 / $3,698.47
| Facility | | $1,411.20 | $2,675.92 | $3,698.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.40 / $1,058.40 / $1,128.96
| Professional | | $1,058.40 | $1,058.40 | $1,128.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $221.14 / $221.14 / $2,097.69
| Facility | | $221.14 | $221.14 | $2,097.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.39 / $1,165.39 / $2,673.29
| Professional | | $1,165.39 | $1,165.39 | $2,673.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $2,313.16
| Professional | | $1,172.56 | $1,172.56 | $2,313.16 |