- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,264.00 / $3,264.00 / $3,264.00
| Facility | | $3,264.00 | $3,264.00 | $3,264.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.20 / $3,187.20 / $3,264.00
| Professional | | $3,187.20 | $3,187.20 | $3,264.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,264.00 / $3,264.00 / $3,264.00
| Facility | | $3,264.00 | $3,264.00 | $3,264.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,264.00 / $3,264.00 / $3,264.00
| Professional | | $3,264.00 | $3,264.00 | $3,264.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,049.60 / $3,200.00 / $3,840.00
| Professional | | $3,049.60 | $3,200.00 | $3,840.00 |