- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,164.09 / $3,164.09 / $3,164.09
| Facility | | $3,164.09 | $3,164.09 | $3,164.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.00 / $3,164.09 / $3,164.09
| Professional | | $1,607.00 | $3,164.09 | $3,164.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.82 / $2,545.82 / $2,545.82
| Professional | | $2,545.82 | $2,545.82 | $2,545.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,264.80 / $2,264.80 / $3,743.74
| Facility | | $2,264.80 | $2,264.80 | $3,743.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.30 / $2,264.80 / $3,278.15
| Professional | | $1,653.30 | $2,264.80 | $3,278.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.32 / $1,877.84 / $2,585.16
| Professional | | $1,112.32 | $1,877.84 | $2,585.16 |