- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,106.75 / $3,106.75 / $3,106.75
| Facility | | $3,106.75 | $3,106.75 | $3,106.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,033.65 / $3,033.65 / $3,106.75
| Professional | | $3,033.65 | $3,033.65 | $3,106.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,045.83 / $3,045.83 / $3,045.83
| Facility | | $3,045.83 | $3,045.83 | $3,045.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,045.83 / $3,045.83 / $3,045.83
| Professional | | $3,045.83 | $3,045.83 | $3,045.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,890.00 / $2,890.00 / $2,890.00
| Facility | | $2,890.00 | $2,890.00 | $2,890.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,045.83 / $3,045.83 / $3,168.89
| Professional | | $3,045.83 | $3,045.83 | $3,168.89 |