- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.12 / $1,841.12 / $1,841.12
| Professional | | $1,841.12 | $1,841.12 | $1,841.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $5,101.79 / $5,759.72
| Facility | | $0.02 | $5,101.79 | $5,759.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,355.94 / $7,355.94 / $7,355.94
| Facility | | $7,355.94 | $7,355.94 | $7,355.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,859.20 / $2,859.20 / $3,574.00
| Professional | | $2,859.20 | $2,859.20 | $3,574.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.80 / $1,492.80 / $3,588.44
| Professional | | $870.80 | $1,492.80 | $3,588.44 |