- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,106.75 / $3,106.75 / $3,106.75
| Facility | | $3,106.75 | $3,106.75 | $3,106.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,106.75 / $3,106.75 / $3,640.38
| Professional | | $3,106.75 | $3,106.75 | $3,640.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,924.00 / $2,924.00 / $2,924.00
| Professional | | $2,924.00 | $2,924.00 | $2,924.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,355.29 / $3,355.29 / $3,355.29
| Professional | | $3,355.29 | $3,355.29 | $3,355.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,045.83 / $3,045.83 / $3,728.10
| Professional | | $3,045.83 | $3,045.83 | $3,728.10 |