- 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 / $1,361.01
| Professional | | $1,237.28 | $1,237.28 | $1,361.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,190.61 / $1,400.73 / $1,400.73
| Facility | | $1,190.61 | $1,400.73 | $1,400.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.61 / $1,330.69 / $1,400.73
| Professional | | $114.61 | $1,330.69 | $1,400.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Facility | | $1,237.28 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,335.09 / $1,739.42
| Professional | | $1,237.28 | $1,335.09 | $1,739.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,190.44 / $1,964.23 / $3,277.72
| Facility | | $1,190.44 | $1,964.23 | $3,277.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.97 / $1,190.44 / $1,679.60
| Professional | | $1,055.97 | $1,190.44 | $1,679.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,267.16 / $1,321.96 / $1,626.19
| Facility | | $1,267.16 | $1,321.96 | $1,626.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.16 / $1,428.53 / $2,012.32
| Professional | | $1,267.16 | $1,428.53 | $2,012.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.97 / $1,237.28 / $1,361.01
| Professional | | $1,055.97 | $1,237.28 | $1,361.01 |