- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,978.93 / $4,978.93 / $4,978.93
| Facility | | $4,978.93 | $4,978.93 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.47 / $4,978.93 / $8,445.12
| Professional | | $898.47 | $4,978.93 | $8,445.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,978.93 / $8,054.78 / $10,190.40
| Facility | | $4,978.93 | $8,054.78 | $10,190.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.47 / $4,978.93 / $8,445.12
| Professional | | $898.47 | $4,978.93 | $8,445.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,248.22 / $3,593.88 / $5,989.80
| Professional | | $3,248.22 | $3,593.88 | $5,989.80 |