- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.08 / $1,052.08 / $1,052.08
| Facility | | $1,052.08 | $1,052.08 | $1,052.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.10 / $1,052.08 / $1,052.08
| Professional | | $687.10 | $1,052.08 | $1,052.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.71 / $500.00 / $500.00
| Professional | | $456.71 | $500.00 | $500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.08 / $1,136.25 / $2,340.17
| Facility | | $1,052.08 | $1,136.25 | $2,340.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.01 / $1,463.01 / $1,463.01
| Professional | | $1,463.01 | $1,463.01 | $1,463.01 |