- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.89 / $1,052.89 / $1,052.89
| Facility | | $1,052.89 | $1,052.89 | $1,052.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.89 / $1,052.89 / $1,158.18
| Professional | | $1,052.89 | $1,052.89 | $1,158.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.89 / $1,052.89 / $1,052.89
| Facility | | $1,052.89 | $1,052.89 | $1,052.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.89 / $1,052.89 / $1,052.89
| Professional | | $1,052.89 | $1,052.89 | $1,052.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.96 / $1,052.89 / $1,052.89
| Professional | | $894.96 | $1,052.89 | $1,052.89 |