- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,055.45 / $4,055.45 / $4,055.45
| Facility | | $4,055.45 | $4,055.45 | $4,055.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,365.46 / $3,365.46 / $4,055.45
| Professional | | $3,365.46 | $3,365.46 | $4,055.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,631.16 / $6,589.74 / $6,703.64
| Professional | | $5,631.16 | $6,589.74 | $6,703.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,715.00 / $5,772.15 / $7,258.05
| Professional | | $5,715.00 | $5,772.15 | $7,258.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,629.66 / $4,055.45 / $5,916.73
| Facility | | $2,629.66 | $4,055.45 | $5,916.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.80 / $2,521.60 / $3,471.16
| Professional | | $1,260.80 | $2,521.60 | $3,471.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.56 / $2,162.91 / $3,471.16
| Professional | | $1,050.56 | $2,162.91 | $3,471.16 |