- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,630.78 / $3,630.78
| Facility | | $3,090.30 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $3,630.78
| Professional | | $2,884.03 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $5,754.40
| Facility | | $3,090.30 | $3,090.30 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $16,218.10 / $16,218.10
| Professional | | $3,090.30 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,019.95 / $3,630.78
| Professional | | $2,951.21 | $3,019.95 | $3,630.78 |