- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,336.09 / $2,431.67 / $2,672.18
| Facility | | $1,336.09 | $2,431.67 | $2,672.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.51 / $2,431.67 / $2,672.18
| Professional | | $1,055.51 | $2,431.67 | $2,672.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,336.09 / $1,336.09 / $1,336.09
| Facility | | $1,336.09 | $1,336.09 | $1,336.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.09 / $1,336.09 / $1,336.09
| Professional | | $1,336.09 | $1,336.09 | $1,336.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $801.65 / $2,271.35
| Professional | | $561.16 | $801.65 | $2,271.35 |