- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.71 / $1,069.71 / $1,283.65
| Facility | | $1,069.71 | $1,069.71 | $1,283.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.71 / $1,111.66 / $1,365.15
| Professional | | $1,069.71 | $1,111.66 | $1,365.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.40 / $1,120.40 / $1,120.40
| Professional | | $1,120.40 | $1,120.40 | $1,120.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.19 / $144.19 / $211.75
| Facility | | $144.19 | $144.19 | $211.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.56 / $144.19 / $211.75
| Professional | | $122.56 | $144.19 | $211.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.17 / $870.26 / $1,637.09
| Professional | | $580.17 | $870.26 | $1,637.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.51 / $1,736.77 / $2,210.42
| Professional | | $1,567.51 | $1,736.77 | $2,210.42 |