- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,575.47 / $3,575.47 / $3,575.47
| Facility | | $3,575.47 | $3,575.47 | $3,575.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $3,128.53 / $3,575.47
| Professional | | $2,979.56 | $3,128.53 | $3,575.47 |
- 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 / $3,091.99
| Professional | | $2,979.55 | $2,979.55 | $3,091.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,681.60 / $2,979.56 / $3,039.15
| Professional | | $2,681.60 | $2,979.56 | $3,039.15 |