- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,337.65 / $2,337.65 / $2,337.65
| Facility | | $2,337.65 | $2,337.65 | $2,337.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.65 / $2,337.65 / $2,337.65
| Professional | | $2,337.65 | $2,337.65 | $2,337.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,922.06 / $3,623.00 / $7,480.00
| Professional | | $2,922.06 | $3,623.00 | $7,480.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,674.97 / $4,674.97 / $4,674.97
| Facility | | $4,674.97 | $4,674.97 | $4,674.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,802.23 / $3,802.23 / $5,025.68
| Professional | | $3,802.23 | $3,802.23 | $5,025.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.81 / $981.81 / $2,337.65
| Professional | | $981.81 | $981.81 | $2,337.65 |