- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,817.65 / $2,817.65 / $2,817.65
| Facility | | $2,817.65 | $2,817.65 | $2,817.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,817.65 / $2,817.65 / $2,817.65
| Professional | | $2,817.65 | $2,817.65 | $2,817.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,817.65 / $2,817.65 / $2,817.65
| Facility | | $2,817.65 | $2,817.65 | $2,817.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.89 / $1,748.89 / $2,817.65
| Professional | | $1,748.89 | $1,748.89 | $2,817.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $816.15 / $1,943.21
| Professional | | $816.15 | $816.15 | $1,943.21 |