- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,286.25 / $1,286.25 / $1,286.25
| Facility | | $1,286.25 | $1,286.25 | $1,286.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.09 / $1,060.09 / $1,286.25
| Professional | | $1,060.09 | $1,060.09 | $1,286.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,019.09 / $2,362.80 / $2,403.64
| Professional | | $2,019.09 | $2,362.80 | $2,403.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,051.25 / $2,071.76 / $2,605.09
| Professional | | $2,051.25 | $2,071.76 | $2,605.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.07 / $1,286.25 / $7,933.12
| Facility | | $106.07 | $1,286.25 | $7,933.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.33 / $868.03 / $1,248.51
| Professional | | $596.33 | $868.03 | $1,248.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.02 / $868.03 / $1,248.51
| Professional | | $496.02 | $868.03 | $1,248.51 |