- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,317.53 / $2,317.53 / $2,317.53
| Facility | | $2,317.53 | $2,317.53 | $2,317.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,649.82 / $2,021.53 / $2,887.44
| Professional | | $1,649.82 | $2,021.53 | $2,887.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $1,472.88 / $3,637.50
| Professional | | $192.51 | $1,472.88 | $3,637.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.91 / $251.91 / $2,060.08
| Professional | | $251.91 | $251.91 | $2,060.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.51 / $280.66 / $1,889.02
| Professional | | $154.51 | $280.66 | $1,889.02 |