- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $879.52 / $879.52 / $879.52
| Facility | | $879.52 | $879.52 | $879.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.52 / $1,043.94 / $1,043.94
| Professional | | $879.52 | $1,043.94 | $1,043.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.31 / $1,336.43 / $1,369.67
| Professional | | $1,130.31 | $1,336.43 | $1,369.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.88 / $1,759.29 / $2,212.17
| Professional | | $1,741.88 | $1,759.29 | $2,212.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $571.79 / $1,043.94 / $6,411.18
| Facility | | $571.79 | $1,043.94 | $6,411.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.61 / $624.63 / $1,005.17
| Professional | | $481.61 | $624.63 | $1,005.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.22 / $624.63 / $1,434.78
| Professional | | $472.22 | $624.63 | $1,434.78 |