- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,949.84 / $1,949.84
| Facility | | $1,230.27 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,202.26 / $1,230.27
| Professional | | $1,148.15 | $1,202.26 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $389.05 / $1,148.15
| Professional | | $331.13 | $389.05 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $794.33 / $1,230.27
| Professional | | $398.11 | $794.33 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $1,258.93
| Professional | | $1,071.52 | $1,202.26 | $1,258.93 |