- 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
- Facility
- Modifier
- Low / Median / High Price
- $1,940.71 / $3,034.83 / $4,722.57
| Facility | | $1,940.71 | $3,034.83 | $4,722.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.08 / $1,052.08 / $1,262.50
| Facility | | $1,052.08 | $1,052.08 | $1,262.50 |
- 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 |