- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,228.67 / $2,228.67 / $2,228.67
| Facility | | $2,228.67 | $2,228.67 | $2,228.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,228.67 / $2,228.67 / $2,228.67
| Professional | | $2,228.67 | $2,228.67 | $2,228.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,228.67 / $2,228.67 / $2,228.67
| Facility | | $2,228.67 | $2,228.67 | $2,228.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.32 / $1,383.32 / $2,228.67
| Professional | | $1,383.32 | $1,383.32 | $2,228.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,844.42 / $1,844.42 / $1,844.42
| Facility | | $1,844.42 | $1,844.42 | $1,844.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.54 / $645.54 / $1,537.02
| Professional | | $645.54 | $645.54 | $1,537.02 |