- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,190.44 / $1,237.28 / $1,237.28
| Facility | | $1,190.44 | $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
- $402.90 / $402.90 / $402.90
| Facility | | $402.90 | $402.90 | $402.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.90 / $402.90 / $402.90
| Professional | | $402.90 | $402.90 | $402.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.25 / $1,167.25 / $1,890.00
| Facility | | $1,167.25 | $1,167.25 | $1,890.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Professional | | $1,237.28 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.56 / $1,311.52 / $2,203.35
| Facility | | $106.56 | $1,311.52 | $2,203.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.64 / $1,361.01 / $1,756.94
| Professional | | $1,348.64 | $1,361.01 | $1,756.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.97 / $1,237.28 / $1,237.28
| Professional | | $1,055.97 | $1,237.28 | $1,237.28 |