- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,475.20 / $5,475.20 / $11,634.80
| Facility | | $5,475.20 | $5,475.20 | $11,634.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.20 / $583.20 / $583.20
| Professional | | $583.20 | $583.20 | $583.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,190.08 / $2,190.08 / $3,558.88
| Professional | | $2,190.08 | $2,190.08 | $3,558.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,475.20 / $5,475.20 / $5,529.95
| Professional | | $5,475.20 | $5,475.20 | $5,529.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,475.20 / $5,475.20 / $8,869.82
| Facility | | $5,475.20 | $5,475.20 | $8,869.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.20 / $583.20 / $5,475.20
| Professional | | $583.20 | $583.20 | $5,475.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,792.35 / $3,285.12 / $9,581.60
| Professional | | $2,792.35 | $3,285.12 | $9,581.60 |