- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $913.19 / $913.19 / $913.19
| Facility | | $913.19 | $913.19 | $913.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $913.19 / $1,109.72 / $2,088.88
| Professional | | $913.19 | $1,109.72 | $2,088.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,454.31 / $1,552.76 / $2,484.96
| Facility | | $1,454.31 | $1,552.76 | $2,484.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.51 / $1,133.51 / $3,519.75
| Professional | | $1,133.51 | $1,133.51 | $3,519.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,270.19 / $2,286.16 / $3,255.30
| Professional | | $2,270.19 | $2,286.16 | $3,255.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,365.23 / $2,484.96 / $2,484.96
| Professional | | $2,365.23 | $2,484.96 | $2,484.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.48 / $1,328.31 / $2,484.96
| Professional | | $1,120.48 | $1,328.31 | $2,484.96 |