- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,082.40 / $4,082.40 / $5,637.60
| Facility | | $4,082.40 | $4,082.40 | $5,637.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,944.00 / $3,142.80 / $4,082.40
| Professional | | $1,944.00 | $3,142.80 | $4,082.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,106.00 / $2,442.96 / $5,812.56
| Facility | | $2,106.00 | $2,442.96 | $5,812.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,916.00 / $2,916.00 / $2,916.00
| Facility | | $2,916.00 | $2,916.00 | $2,916.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.80 / $1,944.00 / $3,240.00
| Professional | | $1,360.80 | $1,944.00 | $3,240.00 |