- 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
- $3,854.52 / $3,947.40 / $3,947.40
| Professional | | $3,854.52 | $3,947.40 | $3,947.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,470.64 / $6,470.64 / $6,470.64
| Facility | | $6,470.64 | $6,470.64 | $6,470.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,470.64 / $6,470.64 / $6,470.64
| Professional | | $6,470.64 | $6,470.64 | $6,470.64 |
- 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 / $3,986.10
| Professional | | $3,870.00 | $3,870.00 | $3,986.10 |