- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,075.76 / $1,075.76 / $1,075.76
| Facility | | $1,075.76 | $1,075.76 | $1,075.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.71 / $1,651.71 / $1,651.71
| Professional | | $1,651.71 | $1,651.71 | $1,651.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $454.24 / $473.78 / $588.77
| Facility | | $454.24 | $473.78 | $588.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.24 / $473.78 / $588.77
| Professional | | $454.24 | $473.78 | $588.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.00 / $4.00 / $4.00
| Professional | | $4.00 | $4.00 | $4.00 |