- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,015.62 / $1,015.62 / $1,015.62
| Facility | | $1,015.62 | $1,015.62 | $1,015.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.62 / $1,015.62 / $1,015.62
| Professional | | $1,015.62 | $1,015.62 | $1,015.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.08 / $1,040.08 / $1,040.08
| Professional | | $1,040.08 | $1,040.08 | $1,040.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,280.91 / $1,597.38 / $2,293.26
| Facility | | $1,280.91 | $1,597.38 | $2,293.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.70 / $1,019.70 / $1,019.70
| Professional | | $1,019.70 | $1,019.70 | $1,019.70 |