- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,443.58 / $2,443.58 / $2,443.58
| Facility | | $2,443.58 | $2,443.58 | $2,443.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,443.58 / $2,443.58 / $2,443.58
| Professional | | $2,443.58 | $2,443.58 | $2,443.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,458.00 / $2,569.15 / $3,133.89
| Professional | | $2,458.00 | $2,569.15 | $3,133.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.32 / $2,679.32 / $2,679.32
| Professional | | $2,679.32 | $2,679.32 | $2,679.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.89 / $2,979.89 / $9,100.37
| Professional | | $2,979.89 | $2,979.89 | $9,100.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,524.75 / $2,287.12 / $3,909.13
| Professional | | $1,524.75 | $2,287.12 | $3,909.13 |