- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Facility | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,651.66 / $3,739.65 / $3,739.65
| Professional | | $3,651.66 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $379.53 / $3,739.65 / $3,739.65
| Facility | | $379.53 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Professional | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,666.33 / $3,666.33 / $3,776.32
| Professional | | $3,666.33 | $3,666.33 | $3,776.32 |