- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $1,809.44
| Facility | | $1,808.65 | $1,808.65 | $1,809.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $3,112.30
| Professional | | $1,808.65 | $1,808.65 | $3,112.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,177.85 / $6,283.58 / $8,453.43
| Facility | | $5,177.85 | $6,283.58 | $8,453.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.46 / $1,808.65 / $1,808.65
| Professional | | $1,528.46 | $1,808.65 | $1,808.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $1,808.65
| Facility | | $1,808.65 | $1,808.65 | $1,808.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $2,104.19
| Professional | | $1,808.65 | $1,808.65 | $2,104.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $1,808.65
| Professional | | $1,808.65 | $1,808.65 | $1,808.65 |