- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,266.07 / $2,304.25 / $2,532.14
| Facility | | $1,266.07 | $2,304.25 | $2,532.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.20 / $2,304.25 / $2,532.14
| Professional | | $1,000.20 | $2,304.25 | $2,532.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,266.07 / $1,266.07 / $1,266.07
| Facility | | $1,266.07 | $1,266.07 | $1,266.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.07 / $1,266.07 / $1,266.07
| Professional | | $1,266.07 | $1,266.07 | $1,266.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.75 / $759.64 / $1,899.11
| Professional | | $531.75 | $759.64 | $1,899.11 |