- 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 / $3,814.25
| Professional | | $1,557.09 | $1,557.09 | $3,814.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,504.33 / $1,534.42 / $8,681.44
| Facility | | $1,504.33 | $1,534.42 | $8,681.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.54 / $1,534.42 / $1,534.42
| Professional | | $1,227.54 | $1,534.42 | $1,534.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,557.09 / $1,557.09 / $3,814.25
| Facility | | $1,557.09 | $1,557.09 | $3,814.25 |