- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.50 / $977.50 / $977.50
| Facility | | $977.50 | $977.50 | $977.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.50 / $1,078.08 / $1,743.58
| Professional | | $977.50 | $1,078.08 | $1,743.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,424.68 / $1,424.68 / $2,659.95
| Facility | | $1,424.68 | $1,424.68 | $2,659.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.02 / $1,040.02 / $3,478.88
| Professional | | $1,040.02 | $1,040.02 | $3,478.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,430.07 / $2,447.15 / $3,484.53
| Professional | | $2,430.07 | $2,447.15 | $3,484.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,597.61 / $2,659.95 / $2,659.95
| Professional | | $2,597.61 | $2,659.95 | $2,659.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.47 / $1,380.47 / $2,659.95
| Professional | | $1,137.47 | $1,380.47 | $2,659.95 |