- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,466.84 / $7,585.78
| Facility | | $2,238.72 | $4,466.84 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $6,309.57 / $7,585.78
| Facility | | $3,388.44 | $6,309.57 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,630.27 / $2,884.03
| Professional | | $2,238.72 | $2,630.27 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,454.71
| Facility | | $2,238.72 | $2,238.72 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,344.23 / $3,019.95
| Professional | | $2,238.72 | $2,344.23 | $3,019.95 |