- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,643.84 / $2,643.84 / $7,793.18
| Facility | | $2,643.84 | $2,643.84 | $7,793.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,550.53 / $2,643.84 / $2,839.79
| Professional | | $2,550.53 | $2,643.84 | $2,839.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,643.84 / $2,643.84 / $2,643.84
| Facility | | $2,643.84 | $2,643.84 | $2,643.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,643.84 / $2,643.84 / $2,643.84
| Professional | | $2,643.84 | $2,643.84 | $2,643.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,470.17 / $2,592.00 / $3,110.40
| Professional | | $2,470.17 | $2,592.00 | $3,110.40 |