- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,723.07 / $2,723.07 / $2,723.07
| Facility | | $2,723.07 | $2,723.07 | $2,723.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,723.07 / $2,723.07 / $3,242.84
| Professional | | $2,723.07 | $2,723.07 | $3,242.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,609.61 / $7,091.97 / $9,718.19
| Facility | | $3,609.61 | $7,091.97 | $9,718.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,609.61 / $3,887.28 / $6,303.97
| Professional | | $3,609.61 | $3,887.28 | $6,303.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,943.38 / $3,943.38 / $6,811.37
| Facility | | $3,943.38 | $3,943.38 | $6,811.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,878.67 / $3,943.38 / $28,548.52
| Professional | | $2,878.67 | $3,943.38 | $28,548.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,770.46 / $3,661.05 / $4,617.43
| Professional | | $2,770.46 | $3,661.05 | $4,617.43 |