- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,214.63 / $1,263.21
| Facility | | $1,214.63 | $1,214.63 | $1,263.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,214.63 / $1,464.40
| Professional | | $1,214.63 | $1,214.63 | $1,464.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Professional | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,136.00 / $2,136.00 / $2,136.00
| Facility | | $2,136.00 | $2,136.00 | $2,136.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.85 / $1,214.63 / $1,428.41
| Professional | | $485.85 | $1,214.63 | $1,428.41 |