- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,778.28
| Facility | | $1,230.27 | $1,230.27 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,230.27 / $1,778.28
| Professional | | $1,174.90 | $1,230.27 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,122.02
| Facility | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.29 / $51.29 / $51.29
| Professional | | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Professional | | $1,258.93 | $1,258.93 | $1,258.93 |
- 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
- $1,230.27 / $1,288.25 / $2,290.87
| Professional | | $1,230.27 | $1,288.25 | $2,290.87 |