- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $4,463.00
| Facility | | $2,672.64 | $2,672.64 | $4,463.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.64 / $3,671.60 / $4,463.00
| Professional | | $2,672.64 | $3,671.60 | $4,463.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,496.69 / $4,079.47 / $5,316.48
| Facility | | $2,496.69 | $4,079.47 | $5,316.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.64 / $3,671.60 / $4,463.00
| Professional | | $2,672.64 | $3,671.60 | $4,463.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,694.63 / $2,047.28 / $3,412.13
| Professional | | $1,694.63 | $2,047.28 | $3,412.13 |