- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,128.01 / $1,128.01 / $1,128.01
| Facility | | $1,128.01 | $1,128.01 | $1,128.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.01 / $1,289.15 / $1,319.53
| Professional | | $1,128.01 | $1,289.15 | $1,319.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.16 / $1,747.16 / $1,747.16
| Facility | | $1,747.16 | $1,747.16 | $1,747.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,747.16 / $1,747.16
| Professional | | $1,275.43 | $1,747.16 | $1,747.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $728.07 / $1,579.01 / $11,750.92
| Facility | | $728.07 | $1,579.01 | $11,750.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.85 / $1,490.29 / $2,661.40
| Professional | | $751.85 | $1,490.29 | $2,661.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.85 / $1,253.10 / $1,698.83
| Professional | | $751.85 | $1,253.10 | $1,698.83 |