- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.42 / $1,007.42 / $1,007.42
| Facility | | $1,007.42 | $1,007.42 | $1,007.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.86 / $1,007.42 / $1,675.28
| Professional | | $971.86 | $1,007.42 | $1,675.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,177.85 / $6,283.58 / $8,453.43
| Facility | | $5,177.85 | $6,283.58 | $8,453.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.67 / $987.67 / $987.67
| Professional | | $987.67 | $987.67 | $987.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,046.93 / $1,046.93
| Facility | | $1,046.93 | $1,046.93 | $1,046.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,046.93 / $1,951.46
| Professional | | $1,046.93 | $1,046.93 | $1,951.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.20 / $1,185.20 / $1,185.20
| Professional | | $1,185.20 | $1,185.20 | $1,185.20 |