- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,947.40 / $3,947.40 / $3,947.40
| Facility | | $3,947.40 | $3,947.40 | $3,947.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,808.08 / $3,947.40 / $3,947.40
| Professional | | $3,808.08 | $3,947.40 | $3,947.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,947.40 / $3,947.40 / $3,947.40
| Facility | | $3,947.40 | $3,947.40 | $3,947.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,947.40 / $3,947.40 / $3,947.40
| Professional | | $3,947.40 | $3,947.40 | $3,947.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,870.00 / $3,870.00 / $4,644.00
| Professional | | $3,870.00 | $3,870.00 | $4,644.00 |