- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,230.27 / $1,479.11
| Professional | | $1,174.90 | $1,230.27 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $2,454.71
| Facility | | $1,548.82 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,659.59
| Professional | | $1,258.93 | $1,258.93 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.26 / $512.86 / $1,288.25
| Facility | | $1.26 | $512.86 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,288.25 / $1,513.56
| Professional | | $1,202.26 | $1,288.25 | $1,513.56 |