- 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 / $2,323.42
| Professional | | $1,908.26 | $1,908.26 | $2,323.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,810.81 / $6,104.22 / $7,471.56
| Facility | | $4,810.81 | $6,104.22 | $7,471.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,883.38 / $6,104.22 / $6,226.30
| Professional | | $4,883.38 | $6,104.22 | $6,226.30 |
- 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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,908.26 / $1,908.26 / $3,224.96
| Facility | | $1,908.26 | $1,908.26 | $3,224.96 |