- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,901.66 / $2,901.66 / $2,901.66
| Facility | | $2,901.66 | $2,901.66 | $2,901.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $3,247.71 / $3,277.51
| Professional | | $2,979.56 | $3,247.71 | $3,277.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,422.50 / $2,850.00 / $2,850.00
| Professional | | $2,422.50 | $2,850.00 | $2,850.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,810.90 / $2,810.90 / $2,810.90
| Facility | | $2,810.90 | $2,810.90 | $2,810.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.55 / $4,216.35 / $4,216.35
| Professional | | $2,979.55 | $4,216.35 | $4,216.35 |
- 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 |