- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,105.53 / $1,105.53 / $1,263.46
| Facility | | $1,105.53 | $1,105.53 | $1,263.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.89 / $1,105.53 / $1,263.46
| Professional | | $1,052.89 | $1,105.53 | $1,263.46 |
- 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
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.66 / $1,052.89 / $1,368.76
| Professional | | $968.66 | $1,052.89 | $1,368.76 |