- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,768.95 / $3,768.95 / $3,768.95
| Facility | | $3,768.95 | $3,768.95 | $3,768.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,768.95 / $3,768.95 / $3,768.95
| Professional | | $3,768.95 | $3,768.95 | $3,768.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,493.06 / $2,164.52 / $3,798.60
| Facility | | $1,493.06 | $2,164.52 | $3,798.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,768.95 / $3,768.95 / $6,595.66
| Facility | | $3,768.95 | $3,768.95 | $6,595.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.19 / $2,371.19 / $3,768.95
| Professional | | $2,371.19 | $2,371.19 | $3,768.95 |