- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,740.75 / $3,740.75 / $3,740.75
| Facility | | $3,740.75 | $3,740.75 | $3,740.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,899.88 / $3,740.75 / $3,740.75
| Professional | | $1,899.88 | $3,740.75 | $3,740.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,312.12 / $3,312.12 / $3,312.12
| Professional | | $3,312.12 | $3,312.12 | $3,312.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,600.52 / $3,600.52 / $4,539.22
| Facility | | $3,600.52 | $3,600.52 | $4,539.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.44 / $3,600.52 / $3,974.71
| Professional | | $3,060.44 | $3,600.52 | $3,974.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.50 / $2,220.08 / $3,114.68
| Professional | | $1,347.50 | $2,220.08 | $3,114.68 |