- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,023.29 / $1,230.27
| Professional | | $977.24 | $1,023.29 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,949.84
| Facility | | $1,047.13 | $1,047.13 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $5,495.41 / $5,495.41
| Professional | | $1,047.13 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,071.52 / $1,230.27
| Professional | | $1,023.29 | $1,071.52 | $1,230.27 |