- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $2,061.42 / $2,061.42
| Facility | | $1,227.04 | $2,061.42 | $2,061.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,227.04
| Professional | | $1,227.04 | $1,227.04 | $1,227.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $412.00 / $578.29 / $917.01
| Facility | | $412.00 | $578.29 | $917.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,263.84 / $1,830.62
| Facility | | $1,227.04 | $1,263.84 | $1,830.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $592.65 / $594.58 / $629.69
| Facility | | $592.65 | $594.58 | $629.69 |