- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,150.40 / $3,410.10 / $37,607.93
| Facility | | $3,150.40 | $3,410.10 | $37,607.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $4,972.50
| Professional | | $402.32 | $402.32 | $4,972.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.93 / $1,054.93 / $1,054.93
| Professional | | $1,054.93 | $1,054.93 | $1,054.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $426.46
| Facility | | $402.32 | $402.32 | $426.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |