- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,811.41 / $1,811.41 / $1,811.41
| Facility | | $1,811.41 | $1,811.41 | $1,811.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.41 / $1,811.41 / $4,386.37
| Professional | | $1,811.41 | $1,811.41 | $4,386.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,702.66 / $3,061.28 / $7,412.97
| Facility | | $2,702.66 | $3,061.28 | $7,412.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,863.82 / $6,841.12 / $9,421.20
| Facility | | $5,863.82 | $6,841.12 | $9,421.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.00 / $2,714.00 / $2,714.00
| Facility | | $2,714.00 | $2,714.00 | $2,714.00 |