- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,348.96 / $1,621.81
| Professional | | $1,288.25 | $1,348.96 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $1,380.38 / $1,380.38
| Facility | | $169.82 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,548.82 / $3,630.78
| Facility | | $1,288.25 | $1,548.82 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $5,754.40
| Professional | | $1,348.96 | $1,348.96 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $1,621.81
| Facility | | $1,047.13 | $1,230.27 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,348.96 / $1,348.96
| Professional | | $125.89 | $1,348.96 | $1,348.96 |