- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,975.35 / $2,975.35 / $2,975.35
| Facility | | $2,975.35 | $2,975.35 | $2,975.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,975.35 / $2,975.35 / $2,975.35
| Professional | | $2,975.35 | $2,975.35 | $2,975.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,116.27 / $3,128.24 / $3,815.88
| Professional | | $3,116.27 | $3,128.24 | $3,815.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.13 / $2,958.13 / $2,958.13
| Professional | | $2,958.13 | $2,958.13 | $2,958.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,628.36 / $3,628.36 / $11,080.78
| Professional | | $3,628.36 | $3,628.36 | $11,080.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,856.56 / $2,784.85 / $3,945.20
| Professional | | $1,856.56 | $2,784.85 | $3,945.20 |