- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Facility | | $3,081.45 | $3,081.45 | $3,081.45 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $2,900.19 / $2,900.19 / $2,900.19
| Professional | | $2,900.19 | $2,900.19 | $2,900.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Facility | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,696.72 / $2,696.72 / $2,696.72
| Professional | | $2,696.72 | $2,696.72 | $2,696.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,749.15 / $3,021.04 / $4,896.43
| Professional | | $2,749.15 | $3,021.04 | $4,896.43 |