- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,638.86 / $3,638.86 / $3,638.86
| Facility | | $3,638.86 | $3,638.86 | $3,638.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,638.86 / $3,638.86 / $3,660.83
| Professional | | $3,638.86 | $3,638.86 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,919.73 / $4,611.45 / $4,611.45
| Professional | | $3,919.73 | $4,611.45 | $4,611.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,453.62 / $3,453.62 / $3,453.62
| Facility | | $3,453.62 | $3,453.62 | $3,453.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $5,180.43
| Professional | | $3,660.83 | $3,660.83 | $5,180.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,660.83
| Professional | | $3,660.83 | $3,660.83 | $3,660.83 |