- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Professional | | $1,902.62 | $1,902.62 | $1,902.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.93 / $2,660.29 / $4,433.82
| Facility | | $1,794.93 | $2,660.29 | $4,433.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $4,433.82
| Professional | | $1,902.62 | $1,902.62 | $4,433.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.93 / $2,660.29 / $4,433.82
| Facility | | $1,794.93 | $2,660.29 | $4,433.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $4,433.82
| Professional | | $1,902.62 | $1,902.62 | $4,433.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $5,707.86
| Professional | | $1,902.62 | $1,902.62 | $5,707.86 |