- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,946.00 / $2,946.00 / $2,946.00
| Professional | | $2,946.00 | $2,946.00 | $2,946.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $3,657.49
| Facility | | $3,657.49 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.93 / $3,657.49 / $5,767.50
| Professional | | $390.93 | $3,657.49 | $5,767.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.24 / $1,980.76 / $3,140.24
| Professional | | $1,123.24 | $1,980.76 | $3,140.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.56 / $1,866.56 / $3,305.31
| Professional | | $1,866.56 | $1,866.56 | $3,305.31 |