- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,609.27 / $1,609.27 / $1,609.27
| Facility | | $1,609.27 | $1,609.27 | $1,609.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.27 / $1,609.27 / $1,609.27
| Professional | | $1,609.27 | $1,609.27 | $1,609.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,493.06 / $2,164.52 / $3,798.60
| Facility | | $1,493.06 | $2,164.52 | $3,798.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,609.27 / $1,609.27 / $2,816.22
| Facility | | $1,609.27 | $1,609.27 | $2,816.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.27 / $1,609.27 / $1,609.27
| Professional | | $1,609.27 | $1,609.27 | $1,609.27 |