- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,960.55 / $2,960.55 / $5,891.49
| Facility | | $2,960.55 | $2,960.55 | $5,891.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,960.55 / $2,960.55 / $2,960.55
| Professional | | $2,960.55 | $2,960.55 | $2,960.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,960.55 / $3,230.00 / $4,233.59
| Facility | | $2,960.55 | $3,230.00 | $4,233.59 |
- 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
- 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 |