- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Facility | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,495.82
| Professional | | $1,452.25 | $1,452.25 | $1,495.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $2,336.98
| Facility | | $1.00 | $1.00 | $2,336.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.03 / $1,673.29 / $1,725.04
| Professional | | $1,380.03 | $1,673.29 | $1,725.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,421.28 / $2,611.82 / $3,671.15
| Facility | | $1,421.28 | $2,611.82 | $3,671.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,906.95 / $2,293.86
| Professional | | $1,452.25 | $1,906.95 | $2,293.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,262.30 / $2,393.57 / $3,308.24
| Facility | | $1,262.30 | $2,393.57 | $3,308.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.51 / $1,806.19 / $1,806.19
| Professional | | $1,607.51 | $1,806.19 | $1,806.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.04 / $1,725.04 / $3,801.54
| Facility | | $1,725.04 | $1,725.04 | $3,801.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,725.04 / $1,725.04 / $3,957.07
| Professional | | $1,725.04 | $1,725.04 | $3,957.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $2,632.64
| Professional | | $1,452.25 | $1,452.25 | $2,632.64 |