- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,365.27 / $2,365.27 / $2,365.27
| Facility | | $2,365.27 | $2,365.27 | $2,365.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,365.27 / $2,365.27 / $2,365.27
| Professional | | $2,365.27 | $2,365.27 | $2,365.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,379.33 / $2,486.82 / $3,033.46
| Professional | | $2,379.33 | $2,486.82 | $3,033.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $2,146.96
| Professional | | $2,146.96 | $2,146.96 | $2,146.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.39 / $2,884.39 / $8,808.75
| Professional | | $2,884.39 | $2,884.39 | $8,808.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.89 / $2,213.83 / $3,367.67
| Professional | | $1,475.89 | $2,213.83 | $3,367.67 |