- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,165.39 / $1,165.39 / $1,165.39
| Facility | | $1,165.39 | $1,165.39 | $1,165.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,278.08 / $1,289.81
| Professional | | $1,172.56 | $1,278.08 | $1,289.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.24 / $1,334.40 / $1,334.40
| Professional | | $1,134.24 | $1,334.40 | $1,334.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.19 / $1,106.19 / $1,106.19
| Facility | | $1,106.19 | $1,106.19 | $1,106.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,659.28 / $1,659.28
| Professional | | $1,172.56 | $1,659.28 | $1,659.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,172.56
| Professional | | $1,172.56 | $1,172.56 | $1,172.56 |