- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,908.26 / $1,908.26 / $1,908.26
| Facility | | $1,908.26 | $1,908.26 | $1,908.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.26 / $1,908.26 / $2,501.75
| Professional | | $1,908.26 | $1,908.26 | $2,501.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,321.12 / $2,367.13 / $4,770.41
| Facility | | $2,321.12 | $2,367.13 | $4,770.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,556.30 / $4,183.89 / $4,183.89
| Professional | | $3,556.30 | $4,183.89 | $4,183.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,300.60 / $4,300.60 / $4,300.60
| Facility | | $4,300.60 | $4,300.60 | $4,300.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,300.60 / $4,300.60 / $4,300.60
| Professional | | $4,300.60 | $4,300.60 | $4,300.60 |