- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,190.44 / $1,190.44 / $1,190.44
| Facility | | $1,190.44 | $1,190.44 | $1,190.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.44 / $1,361.01 / $1,546.61
| Professional | | $1,190.44 | $1,361.01 | $1,546.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.25 / $1,237.28 / $1,237.28
| Facility | | $1,167.25 | $1,237.28 | $1,237.28 |
- 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 / $1,546.61 / $1,979.66
| Facility | | $106.56 | $1,546.61 | $1,979.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,311.52 / $1,546.60
| Professional | | $1,237.28 | $1,311.52 | $1,546.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $78.00 / $2,059.14
| Professional | | $30.00 | $78.00 | $2,059.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.74 / $1,484.74 / $1,484.74
| Professional | | $1,484.74 | $1,484.74 | $1,484.74 |
- 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 |