- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,895.75 / $2,895.75 / $2,895.75
| Facility | | $2,895.75 | $2,895.75 | $2,895.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,895.75
| Professional | | $2,784.38 | $2,784.38 | $2,895.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,626.77 / $2,784.38 / $2,784.38
| Facility | | $2,626.77 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Professional | | $2,784.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Professional | | $2,784.38 | $2,784.38 | $2,784.38 |