- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $2,979.56
| Facility | | $2,979.56 | $2,979.56 | $2,979.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $3,277.51
| Professional | | $2,979.56 | $2,979.56 | $3,277.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,979.55 / $2,979.55 / $2,979.55
| Facility | | $2,979.55 | $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
- $2,532.63 / $2,979.56 / $2,979.56
| Professional | | $2,532.63 | $2,979.56 | $2,979.56 |