- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,304.55 / $3,304.55 / $3,304.55
| Facility | | $3,304.55 | $3,304.55 | $3,304.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,304.55 / $3,304.55 / $3,304.55
| Professional | | $3,304.55 | $3,304.55 | $3,304.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,304.55 / $3,304.55 / $3,304.55
| Facility | | $3,304.55 | $3,304.55 | $3,304.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,051.10 / $2,051.10 / $3,304.55
| Professional | | $2,051.10 | $2,051.10 | $3,304.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.18 / $957.18 / $2,279.00
| Professional | | $957.18 | $957.18 | $2,279.00 |