- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,598.86 / $1,812.04 / $2,325.61
| Facility | | $1,598.86 | $1,812.04 | $2,325.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.15 / $1,027.15 / $1,027.15
| Professional | | $1,027.15 | $1,027.15 | $1,027.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,325.61 / $2,325.61 / $2,325.61
| Professional | | $2,325.61 | $2,325.61 | $2,325.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.40 / $2,029.33 / $2,422.51
| Professional | | $1,826.40 | $2,029.33 | $2,422.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,131.81 / $2,325.61 / $2,713.21
| Professional | | $2,131.81 | $2,325.61 | $2,713.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,938.01 / $2,325.61 / $2,907.02
| Professional | | $1,938.01 | $2,325.61 | $2,907.02 |