- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,122.02 / $1,122.02
| Facility | | $1,096.48 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,071.52 / $1,122.02
| Professional | | $1,023.29 | $1,071.52 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Facility | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,041.74 / $2,041.74
| Facility | | $1,096.48 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $5,754.40
| Professional | | $1,096.48 | $1,096.48 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,148.15 / $1,288.25
| Professional | | $1,071.52 | $1,148.15 | $1,288.25 |