- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.63 / $1,017.63 / $1,017.63
| Facility | | $1,017.63 | $1,017.63 | $1,017.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.49 / $841.49 / $1,017.63
| Professional | | $841.49 | $841.49 | $1,017.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.69 / $1,875.51 / $1,907.93
| Professional | | $1,602.69 | $1,875.51 | $1,907.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,627.50 / $1,643.78 / $2,066.92
| Professional | | $1,627.50 | $1,643.78 | $2,066.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $792.38 / $1,017.63 / $7,407.45
| Facility | | $792.38 | $1,017.63 | $7,407.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $559.04 / $829.85 / $1,244.78
| Professional | | $559.04 | $829.85 | $1,244.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.20 / $1,118.09 / $1,244.78
| Professional | | $465.20 | $1,118.09 | $1,244.78 |