- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,946.10 / $1,946.10 / $1,946.10
| Facility | | $1,946.10 | $1,946.10 | $1,946.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,474.34 / $1,946.10 / $2,794.64
| Professional | | $1,474.34 | $1,946.10 | $2,794.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.74 / $1,232.84 / $1,450.41
| Professional | | $184.74 | $1,232.84 | $1,450.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.20 / $1,306.61 / $2,129.92
| Facility | | $630.20 | $1,306.61 | $2,129.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.83 / $251.30 / $1,854.59
| Professional | | $135.83 | $251.30 | $1,854.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.75 / $1,100.01 / $1,741.68
| Professional | | $1,024.75 | $1,100.01 | $1,741.68 |