- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,308.46 / $2,308.46 / $2,308.46
| Facility | | $2,308.46 | $2,308.46 | $2,308.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,265.31 / $4,011.06
| Professional | | $2,100.00 | $2,265.31 | $4,011.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,259.51 / $5,755.84 / $6,806.43
| Professional | | $5,259.51 | $5,755.84 | $6,806.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,260.76 / $6,014.65 / $7,767.04
| Professional | | $3,260.76 | $6,014.65 | $7,767.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,308.46 / $2,722.61 / $6,925.41
| Facility | | $2,308.46 | $2,722.61 | $6,925.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,494.51 / $4,286.72 / $5,847.40
| Professional | | $2,494.51 | $4,286.72 | $5,847.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.19 / $5,078.09 / $5,847.40
| Professional | | $2,511.19 | $5,078.09 | $5,847.40 |