- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,854.52 / $3,854.52 / $3,854.52
| Facility | | $3,854.52 | $3,854.52 | $3,854.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,854.52 / $3,854.52 / $3,854.52
| Professional | | $3,854.52 | $3,854.52 | $3,854.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,947.40 / $3,947.40 / $3,947.40
| Professional | | $3,947.40 | $3,947.40 | $3,947.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $60.00 / $7,305.94
| Professional | | $45.00 | $60.00 | $7,305.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,411.80 / $5,436.22 / $5,722.10
| Professional | | $4,411.80 | $5,436.22 | $5,722.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,870.00 / $3,870.00 / $3,870.00
| Professional | | $3,870.00 | $3,870.00 | $3,870.00 |