- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,338.48 / $2,338.48 / $2,338.48
| Facility | | $2,338.48 | $2,338.48 | $2,338.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.26 / $2,338.48 / $2,501.75
| Professional | | $1,908.26 | $2,338.48 | $2,501.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,080.00 / $4,183.89 / $4,183.89
| Professional | | $4,080.00 | $4,183.89 | $4,183.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,300.60 / $4,300.60 / $4,300.60
| Facility | | $4,300.60 | $4,300.60 | $4,300.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,300.60 / $4,300.60 / $4,300.60
| Professional | | $4,300.60 | $4,300.60 | $4,300.60 |