- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,260.50 / $4,260.50 / $4,260.50
| Facility | | $4,260.50 | $4,260.50 | $4,260.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,345.11 / $3,890.21 / $4,260.50
| Professional | | $2,345.11 | $3,890.21 | $4,260.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,019.14 / $4,019.14 / $5,100.00
| Professional | | $4,019.14 | $4,019.14 | $5,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $248.35
| Professional | | $248.35 | $248.35 | $248.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.31 / $287.20 / $2,342.16
| Professional | | $222.31 | $287.20 | $2,342.16 |