- 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
- $1,148.15 / $1,202.26 / $1,230.27
| Professional | | $1,148.15 | $1,202.26 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,290.87 / $2,290.87
| Facility | | $1,230.27 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $6,456.54
| Professional | | $1,230.27 | $1,230.27 | $6,456.54 |
- 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
- $1,202.26 / $1,202.26 / $1,445.44
| Professional | | $1,202.26 | $1,202.26 | $1,445.44 |