- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.13 / $1,406.13 / $1,406.13
| Facility | | $1,406.13 | $1,406.13 | $1,406.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.98 / $1,243.60 / $1,666.98
| Professional | | $910.98 | $1,243.60 | $1,666.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,530.37 / $1,972.60 / $2,272.07
| Facility | | $1,530.37 | $1,972.60 | $2,272.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.35 / $1,138.06 / $2,000.85
| Professional | | $967.35 | $1,138.06 | $2,000.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,006.83 / $4,006.83 / $4,006.83
| Facility | | $4,006.83 | $4,006.83 | $4,006.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.06 / $1,406.78 / $2,636.87
| Professional | | $1,049.06 | $1,406.78 | $2,636.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.60 / $1,296.72 / $1,832.49
| Professional | | $971.60 | $1,296.72 | $1,832.49 |