- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,355.54 / $2,355.54 / $2,355.54
| Facility | | $2,355.54 | $2,355.54 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.42 / $2,355.54 / $2,426.21
| Professional | | $73.42 | $2,355.54 | $2,426.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.67 / $99.86 / $2,355.54
| Facility | | $64.67 | $99.86 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.42 / $2,355.54 / $2,426.21
| Professional | | $73.42 | $2,355.54 | $2,426.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.44 / $437.19 / $728.65
| Professional | | $398.44 | $437.19 | $728.65 |