- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,528.73 / $2,528.73 / $2,528.73
| Facility | | $2,528.73 | $2,528.73 | $2,528.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,528.73 / $2,528.73 / $2,528.73
| Professional | | $2,528.73 | $2,528.73 | $2,528.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,528.73 / $2,528.73 / $2,528.73
| Facility | | $2,528.73 | $2,528.73 | $2,528.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,569.56 / $1,569.56 / $2,528.73
| Professional | | $1,569.56 | $1,569.56 | $2,528.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $469.55 / $469.55 / $1,117.98
| Professional | | $469.55 | $469.55 | $1,117.98 |