- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,557.09 / $1,557.09 / $1,557.09
| Facility | | $1,557.09 | $1,557.09 | $1,557.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,557.09 / $1,557.09 / $3,044.76
| Professional | | $1,557.09 | $1,557.09 | $3,044.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,837.75 / $8,837.75 / $8,837.75
| Professional | | $8,837.75 | $8,837.75 | $8,837.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,557.09 / $1,557.09 / $3,044.76
| Facility | | $1,557.09 | $1,557.09 | $3,044.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,044.76 / $3,044.76 / $3,044.76
| Professional | | $3,044.76 | $3,044.76 | $3,044.76 |