- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.76 / $1,853.76 / $1,853.76
| Professional | | $1,853.76 | $1,853.76 | $1,853.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,950.00 / $1,950.00 / $1,950.00
| Facility | | $1,950.00 | $1,950.00 | $1,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.82 / $1,950.00 / $2,838.62
| Professional | | $244.82 | $1,950.00 | $2,838.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.50 / $1,930.26 / $4,110.32
| Facility | | $311.50 | $1,930.26 | $4,110.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.82 / $1,950.00 / $2,838.62
| Professional | | $244.82 | $1,950.00 | $2,838.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.33 / $1,253.32 / $1,451.95
| Professional | | $1,210.33 | $1,253.32 | $1,451.95 |