- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,109.46 / $5,109.46 / $5,109.46
| Facility | | $5,109.46 | $5,109.46 | $5,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.20 / $5,109.46 / $8,499.12
| Professional | | $904.20 | $5,109.46 | $8,499.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,109.46 / $8,105.76 / $10,255.68
| Facility | | $5,109.46 | $8,105.76 | $10,255.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.20 / $5,109.46 / $8,499.12
| Professional | | $904.20 | $5,109.46 | $8,499.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,268.98 / $3,616.80 / $4,140.20
| Professional | | $3,268.98 | $3,616.80 | $4,140.20 |