- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.08 / $1,040.08 / $1,050.14
| Facility | | $1,040.08 | $1,040.08 | $1,050.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.62 / $1,040.08 / $1,040.08
| Professional | | $1,015.62 | $1,040.08 | $1,040.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.29 / $125.24 / $219.17
| Facility | | $121.29 | $125.24 | $219.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.08 / $1,040.08 / $1,040.08
| Facility | | $1,040.08 | $1,040.08 | $1,040.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.08 / $1,040.08 / $1,452.36
| Professional | | $1,040.08 | $1,040.08 | $1,452.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.70 / $1,019.70 / $1,223.64
| Professional | | $1,019.70 | $1,019.70 | $1,223.64 |