- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,023.29 / $1,513.56
| Professional | | $660.69 | $1,023.29 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,137.96 / $2,238.72
| Professional | | $1,819.70 | $2,137.96 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,398.83
| Professional | | $1,905.46 | $1,905.46 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.10 / $1,202.26 / $7,413.10
| Facility | | $87.10 | $1,202.26 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $691.83 / $1,148.15
| Professional | | $549.54 | $691.83 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $691.83 / $912.01
| Facility | | $91.20 | $691.83 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $794.33 / $1,584.89
| Professional | | $549.54 | $794.33 | $1,584.89 |