- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,445.20 / $3,445.20 / $3,712.50
| Facility | | $3,445.20 | $3,445.20 | $3,712.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $1,262.25
| Professional | | $1,262.25 | $1,262.25 | $1,262.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,269.38 / $1,593.38 / $4,156.93
| Facility | | $1,269.38 | $1,593.38 | $4,156.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.50 / $1,237.50 / $1,237.50
| Professional | | $1,237.50 | $1,237.50 | $1,237.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $1,262.25
| Professional | | $1,262.25 | $1,262.25 | $1,262.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,445.20 / $3,445.20 / $3,712.50
| Facility | | $3,445.20 | $3,445.20 | $3,712.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $3,712.50
| Professional | | $1,262.25 | $1,262.25 | $3,712.50 |