- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,914.55 / $5,426.36 / $5,426.36
| Facility | | $2,914.55 | $5,426.36 | $5,426.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,811.68 / $2,914.55 / $3,130.56
| Professional | | $2,811.68 | $2,914.55 | $3,130.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,257.44 / $3,257.44 / $3,257.44
| Professional | | $3,257.44 | $3,257.44 | $3,257.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,914.55 / $2,914.55 / $2,914.55
| Facility | | $2,914.55 | $2,914.55 | $2,914.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.55 / $2,914.55 / $2,914.55
| Professional | | $2,914.55 | $2,914.55 | $2,914.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,857.40 / $2,857.40 / $3,428.88
| Professional | | $2,857.40 | $2,857.40 | $3,428.88 |