- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,008.95 / $3,008.95 / $3,008.95
| Facility | | $3,008.95 | $3,008.95 | $3,008.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,008.95 / $3,008.95 / $3,008.95
| Professional | | $3,008.95 | $3,008.95 | $3,008.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,920.71 / $5,424.55 / $7,787.72
| Facility | | $3,920.71 | $5,424.55 | $7,787.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.04 / $3,021.04 / $3,021.04
| Professional | | $3,021.04 | $3,021.04 | $3,021.04 |