- 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 / $1,557.09
| Professional | | $1,557.09 | $1,557.09 | $1,557.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,557.09 / $1,557.09 / $2,958.47
| Facility | | $1,557.09 | $1,557.09 | $2,958.47 |
- 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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $780.65 / $780.65 / $780.65
| Facility | | $780.65 | $780.65 | $780.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.65 / $780.65 / $780.65
| Professional | | $780.65 | $780.65 | $780.65 |