- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,157.08 / $2,157.08 / $2,157.08
| Professional | | $2,157.08 | $2,157.08 | $2,157.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.69 / $3,162.69 / $3,162.69
| Facility | | $3,162.69 | $3,162.69 | $3,162.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.69 / $3,162.69 / $3,162.69
| Professional | | $3,162.69 | $3,162.69 | $3,162.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.49 / $1,741.32 / $3,162.69
| Facility | | $167.49 | $1,741.32 | $3,162.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.69 / $3,779.72 / $4,446.93
| Professional | | $3,162.69 | $3,779.72 | $4,446.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,781.15 / $4,374.26 / $7,056.31
| Professional | | $3,781.15 | $4,374.26 | $7,056.31 |