- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $929.28 / $929.28 / $929.28
| Facility | | $929.28 | $929.28 | $929.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.28 / $1,246.39 / $11,099.70
| Professional | | $929.28 | $1,246.39 | $11,099.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,289.62 / $2,289.62 / $2,289.62
| Facility | | $2,289.62 | $2,289.62 | $2,289.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.42 / $1,671.42 / $4,144.28
| Professional | | $1,671.42 | $1,671.42 | $4,144.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.83 / $2,690.06 / $3,497.07
| Professional | | $1,667.83 | $2,690.06 | $3,497.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,226.62 / $3,598.53 / $3,598.53
| Facility | | $3,226.62 | $3,598.53 | $3,598.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.12 / $2,579.42 / $3,869.13
| Professional | | $2,049.12 | $2,579.42 | $3,869.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,299.70 / $1,439.45 / $2,010.78
| Professional | | $1,299.70 | $1,439.45 | $2,010.78 |