- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,405.11 / $2,405.11 / $2,405.11
| Facility | | $2,405.11 | $2,405.11 | $2,405.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.91 / $2,090.91 / $2,405.11
| Professional | | $2,090.91 | $2,090.91 | $2,405.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,814.65 / $3,327.91 / $3,370.62
| Professional | | $2,814.65 | $3,327.91 | $3,370.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,910.00 / $2,939.10 / $3,695.70
| Professional | | $2,910.00 | $2,939.10 | $3,695.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $366.75 / $2,405.11 / $9,481.87
| Facility | | $366.75 | $2,405.11 | $9,481.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.71 / $205.41 / $2,698.60
| Professional | | $102.71 | $205.41 | $2,698.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $208.49 / $2,698.60
| Professional | | $95.50 | $208.49 | $2,698.60 |