- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $3,704.40
| Facility | | $3,704.40 | $3,704.40 | $3,704.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $3,704.40 / $7,355.76
| Professional | | $782.55 | $3,704.40 | $7,355.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $7,026.86 / $8,876.00
| Facility | | $3,704.40 | $7,026.86 | $8,876.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $3,704.40 / $7,355.76
| Professional | | $782.55 | $3,704.40 | $7,355.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,829.24 / $3,130.20 / $5,217.00
| Professional | | $2,829.24 | $3,130.20 | $5,217.00 |