- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,083.10 / $4,083.10 / $4,083.10
| Facility | | $4,083.10 | $4,083.10 | $4,083.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.46 / $3,388.46 / $4,083.10
| Professional | | $3,388.46 | $3,388.46 | $4,083.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,680.72 / $6,647.75 / $6,762.65
| Professional | | $5,680.72 | $6,647.75 | $6,762.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,767.50 / $5,825.18 / $7,324.73
| Professional | | $5,767.50 | $5,825.18 | $7,324.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,652.80 / $4,083.10 / $5,968.80
| Facility | | $2,652.80 | $4,083.10 | $5,968.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.86 / $2,543.73 / $3,489.36
| Professional | | $1,271.86 | $2,543.73 | $3,489.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $559.58 / $1,866.56 / $3,323.20
| Professional | | $559.58 | $1,866.56 | $3,323.20 |