- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,211.20 / $1,212.36 / $1,212.36
| Facility | | $1,211.20 | $1,212.36 | $1,212.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.36 / $1,212.36 / $1,212.36
| Professional | | $1,212.36 | $1,212.36 | $1,212.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.59 / $1,356.64 / $1,560.14
| Facility | | $1,201.59 | $1,356.64 | $1,560.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,045.15 / $1,045.15
| Professional | | $1,045.15 | $1,045.15 | $1,045.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,711.35 / $2,193.73 / $3,063.53
| Facility | | $1,711.35 | $2,193.73 | $3,063.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,045.15 / $1,045.15
| Professional | | $1,045.15 | $1,045.15 | $1,045.15 |