- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,836.40 / $2,836.40 / $2,836.40
| Facility | | $2,836.40 | $2,836.40 | $2,836.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.26 / $2,501.75 / $2,836.40
| Professional | | $1,908.26 | $2,501.75 | $2,836.40 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $17,597.66 / $17,597.66 / $17,597.66
| Professional | | $17,597.66 | $17,597.66 | $17,597.66 |