- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,274.40 / $1,274.40 / $1,274.40
| Facility | | $1,274.40 | $1,274.40 | $1,274.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,274.40 / $1,274.40
| Professional | | $1,237.28 | $1,274.40 | $1,274.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.47 / $1,237.28 / $1,366.41
| Professional | | $1,140.47 | $1,237.28 | $1,366.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $356.40 / $1,237.28 / $1,274.40
| Facility | | $356.40 | $1,237.28 | $1,274.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,484.73
| Professional | | $1,237.28 | $1,237.28 | $1,484.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $1,425.55 / $1,855.92
| Professional | | $30.00 | $1,425.55 | $1,855.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.97 / $1,237.28 / $1,312.75
| Professional | | $1,055.97 | $1,237.28 | $1,312.75 |