- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,483.93 / $4,483.93 / $4,483.93
| Facility | | $4,483.93 | $4,483.93 | $4,483.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,483.93 / $4,483.93 / $4,483.93
| Professional | | $4,483.93 | $4,483.93 | $4,483.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,518.98 / $4,483.93 / $4,483.93
| Facility | | $2,518.98 | $4,483.93 | $4,483.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,483.93 / $4,483.93 / $6,331.50
| Professional | | $4,483.93 | $4,483.93 | $6,331.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,275.21 / $5,275.21 / $7,640.09
| Professional | | $5,275.21 | $5,275.21 | $7,640.09 |