- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,479.11 / $1,479.11
| Facility | | $1,230.27 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,202.26 / $1,445.44
| Professional | | $1,174.90 | $1,202.26 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $2,290.87
| Facility | | $1,230.27 | $1,230.27 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $6,606.93 / $6,606.93
| Professional | | $1,230.27 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,258.93 / $1,479.11
| Professional | | $1,230.27 | $1,258.93 | $1,479.11 |