- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,831.50 / $1,831.50 / $1,831.50
| Facility | | $1,831.50 | $1,831.50 | $1,831.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,831.50 / $2,411.53 / $2,483.90
| Professional | | $1,831.50 | $2,411.53 | $2,483.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,750.77 / $1,750.77 / $2,462.00
| Professional | | $1,750.77 | $1,750.77 | $2,462.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.33 / $303.33 / $303.33
| Facility | | $303.33 | $303.33 | $303.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.83 / $257.83 / $257.83
| Professional | | $257.83 | $257.83 | $257.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.22 / $196.06 / $2,310.88
| Professional | | $143.22 | $196.06 | $2,310.88 |