- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,251.00 / $2,251.00 / $2,251.00
| Professional | | $2,251.00 | $2,251.00 | $2,251.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,106.14 / $5,106.14 / $5,106.14
| Facility | | $5,106.14 | $5,106.14 | $5,106.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.27 / $5,106.14 / $8,298.75
| Professional | | $560.27 | $5,106.14 | $8,298.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,239.59 / $4,702.63 / $6,817.68
| Professional | | $3,239.59 | $4,702.63 | $6,817.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,091.96 / $2,210.28 / $4,502.00
| Professional | | $2,091.96 | $2,210.28 | $4,502.00 |