- 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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,810.90 / $3,241.28 / $5,402.14
| Facility | | $2,810.90 | $3,241.28 | $5,402.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.55 / $2,979.55 / $5,402.14
| Professional | | $2,979.55 | $2,979.55 | $5,402.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,810.90 / $3,241.28 / $5,402.14
| Facility | | $2,810.90 | $3,241.28 | $5,402.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.55 / $2,979.55 / $5,402.14
| Professional | | $2,979.55 | $2,979.55 | $5,402.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,427.07 / $2,979.56 / $8,938.68
| Professional | | $2,427.07 | $2,979.56 | $8,938.68 |