- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,485.96 / $2,485.96 / $2,485.96
| Facility | | $2,485.96 | $2,485.96 | $2,485.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,485.96 / $2,575.82
| Professional | | $2,396.11 | $2,485.96 | $2,575.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Professional | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $3,078.54 / $3,364.98
| Professional | | $60.00 | $3,078.54 | $3,364.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $284.26 / $315.11 / $5,041.66
| Facility | | $284.26 | $315.11 | $5,041.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $2,495.94 / $2,495.94
| Professional | | $2,495.94 | $2,495.94 | $2,495.94 |