- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $2,979.56
| Facility | | $2,979.56 | $2,979.56 | $2,979.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $3,009.35
| Professional | | $2,979.56 | $2,979.56 | $3,009.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,686.97 / $3,022.42 / $3,272.95
| Professional | | $2,686.97 | $3,022.42 | $3,272.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.55 / $2,979.55 / $2,979.55
| Professional | | $2,979.55 | $2,979.55 | $2,979.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,901.66 / $3,627.25 / $5,363.21
| Facility | | $2,901.66 | $3,627.25 | $5,363.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,863.13 / $2,901.66 / $3,249.86
| Professional | | $2,863.13 | $2,901.66 | $3,249.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $3,235.95
| Professional | | $2,979.56 | $2,979.56 | $3,235.95 |