- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,966.26 / $2,966.26 / $2,966.26
| Professional | | $2,966.26 | $2,966.26 | $2,966.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.98 / $2,911.80 / $3,202.98
| Professional | | $1,751.98 | $2,911.80 | $3,202.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,095.19 / $3,685.49 / $3,685.49
| Facility | | $2,095.19 | $3,685.49 | $3,685.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $3,685.49 / $3,685.49
| Professional | | $192.51 | $3,685.49 | $3,685.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,966.26 / $2,966.26 / $3,111.02
| Professional | | $2,966.26 | $2,966.26 | $3,111.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.03 / $679.98 / $3,143.01
| Professional | | $176.03 | $679.98 | $3,143.01 |