- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,456.28 / $3,456.28 / $3,456.28
| Facility | | $3,456.28 | $3,456.28 | $3,456.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $3,277.51 / $3,724.44
| Professional | | $2,979.56 | $3,277.51 | $3,724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,979.55 / $3,335.82 / $6,812.10
| Facility | | $2,979.55 | $3,335.82 | $6,812.10 |
- 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
- $2,949.76 / $3,277.51 / $3,277.51
| Professional | | $2,949.76 | $3,277.51 | $3,277.51 |
- 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 |