- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $3,009.35
| Facility | | $2,979.56 | $2,979.56 | $3,009.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $3,128.53
| Professional | | $2,979.56 | $2,979.56 | $3,128.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,800.68 / $2,979.55 / $5,696.83
| Facility | | $2,800.68 | $2,979.55 | $5,696.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $2,979.56
| Professional | | $2,979.56 | $2,979.56 | $2,979.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,810.90 / $2,979.55 / $2,979.55
| Facility | | $2,810.90 | $2,979.55 | $2,979.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.55 / $2,979.55 / $2,979.55
| Professional | | $2,979.55 | $2,979.55 | $2,979.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $3,217.92
| Professional | | $2,979.56 | $2,979.56 | $3,217.92 |