- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,841.11 / $1,841.11 / $2,872.13
| Facility | | $1,841.11 | $1,841.11 | $2,872.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,647.31 / $1,841.11 / $1,841.11
| Professional | | $1,647.31 | $1,841.11 | $1,841.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,291.08 / $1,291.08 / $1,359.03
| Facility | | $1,291.08 | $1,291.08 | $1,359.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.08 / $1,359.03 / $1,511.65
| Professional | | $1,291.08 | $1,359.03 | $1,511.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.88 / $2,361.94 / $2,952.44
| Professional | | $560.88 | $2,361.94 | $2,952.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,841.11 / $1,841.11 / $3,383.04
| Facility | | $1,841.11 | $1,841.11 | $3,383.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.11 / $1,860.49 / $2,325.61
| Professional | | $1,841.11 | $1,860.49 | $2,325.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.96 / $1,162.81 / $1,938.01
| Professional | | $813.96 | $1,162.81 | $1,938.01 |