- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,843.00 / $2,843.00 / $2,843.00
| Professional | | $2,843.00 | $2,843.00 | $2,843.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.52 / $1,622.69 / $2,845.25
| Facility | | $1,069.52 | $1,622.69 | $2,845.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.32 / $1,835.32 / $4,088.54
| Professional | | $1,835.32 | $1,835.32 | $4,088.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.00 / $2,097.00 / $3,958.00
| Facility | | $478.00 | $2,097.00 | $3,958.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $726.00 / $2,097.00 / $4,241.00
| Facility | | $726.00 | $2,097.00 | $4,241.00 |