- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,303.28 / $4,303.28 / $4,303.28
| Facility | | $4,303.28 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.38 / $4,303.28 / $6,239.52
| Professional | | $459.38 | $4,303.28 | $6,239.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,117.23 / $3,896.54 / $7,528.96
| Facility | | $3,117.23 | $3,896.54 | $7,528.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.38 / $4,303.28 / $6,239.52
| Professional | | $459.38 | $4,303.28 | $6,239.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.71 / $2,209.71 / $3,682.87
| Professional | | $2,209.71 | $2,209.71 | $3,682.87 |