- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,227.04
| Facility | | $1,227.04 | $1,227.04 | $1,227.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,303.44
| Professional | | $1,227.04 | $1,227.04 | $1,303.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $965.57 / $2,083.21 / $3,664.53
| Facility | | $965.57 | $2,083.21 | $3,664.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,349.74 / $2,085.96
| Facility | | $1,227.04 | $1,349.74 | $2,085.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $581.50 / $586.77 / $628.41
| Facility | | $581.50 | $586.77 | $628.41 |