- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,294.16 / $4,294.16 / $4,294.16
| Facility | | $4,294.16 | $4,294.16 | $4,294.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,294.16 / $4,294.16 / $4,294.16
| Professional | | $4,294.16 | $4,294.16 | $4,294.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,004.79 / $4,135.22 / $6,202.83
| Facility | | $4,004.79 | $4,135.22 | $6,202.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,294.16 / $4,294.16 / $4,294.16
| Facility | | $4,294.16 | $4,294.16 | $4,294.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,294.16 / $4,294.16 / $6,415.98
| Professional | | $4,294.16 | $4,294.16 | $6,415.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,209.96 / $4,209.96 / $6,097.29
| Professional | | $4,209.96 | $4,209.96 | $6,097.29 |