- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,334.50 / $5,334.50 / $5,334.50
| Facility | | $5,334.50 | $5,334.50 | $5,334.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,386.40 / $3,468.00 / $3,725.04
| Professional | | $3,386.40 | $3,468.00 | $3,725.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $3,468.00 / $3,468.00
| Facility | | $3,468.00 | $3,468.00 | $3,468.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,468.00 / $3,468.00 / $5,181.60
| Professional | | $3,468.00 | $3,468.00 | $5,181.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,273.76 / $1,273.76 / $1,273.76
| Facility | | $1,273.76 | $1,273.76 | $1,273.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,400.00 / $3,400.00 / $4,924.22
| Professional | | $3,400.00 | $3,400.00 | $4,924.22 |