- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,128.53 / $3,128.53 / $3,575.47
| Facility | | $3,128.53 | $3,128.53 | $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
- $2,979.55 / $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
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,816.79 / $2,979.56 / $3,873.43
| Professional | | $2,816.79 | $2,979.56 | $3,873.43 |