- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.73 / $1,207.73 / $1,207.73
| Facility | | $1,207.73 | $1,207.73 | $1,207.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,207.73 / $1,207.73
| Professional | | $1,172.56 | $1,207.73 | $1,207.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.90 / $1,172.56 / $1,174.82
| Professional | | $1,121.90 | $1,172.56 | $1,174.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.32 / $1,172.56 / $1,207.73
| Facility | | $115.32 | $1,172.56 | $1,207.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,407.07
| Professional | | $1,172.56 | $1,172.56 | $1,407.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.39 / $1,609.87 / $1,788.75
| Professional | | $1,165.39 | $1,609.87 | $1,788.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,251.69
| Professional | | $1,172.56 | $1,172.56 | $1,251.69 |