- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,098.74 / $3,098.74 / $3,098.74
| Facility | | $3,098.74 | $3,098.74 | $3,098.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $3,098.74
| Professional | | $2,979.56 | $2,979.56 | $3,098.74 |
- 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 / $2,979.56
| Professional | | $2,979.56 | $2,979.56 | $2,979.56 |