- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $3,981.07
| Professional | | $1,621.81 | $1,621.81 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,949.84 / $3,801.89
| Facility | | $1,479.11 | $1,949.84 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $1,659.59 / $3,090.30
| Facility | | $100.00 | $1,659.59 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Professional | | $1,621.81 | $1,621.81 | $1,621.81 |