- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,598.12 / $1,598.12 / $1,598.12
| Facility | | $1,598.12 | $1,598.12 | $1,598.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.94 / $1,598.12 / $1,819.39
| Professional | | $835.94 | $1,598.12 | $1,819.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,040.65 / $2,311.87 / $2,583.10
| Facility | | $2,040.65 | $2,311.87 | $2,583.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,236.28 / $1,901.61 / $2,510.12
| Professional | | $1,236.28 | $1,901.61 | $2,510.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.54 / $1,937.26 / $3,358.03
| Facility | | $219.54 | $1,937.26 | $3,358.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.54 / $1,679.02 / $3,099.72
| Professional | | $219.54 | $1,679.02 | $3,099.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $1,916.91
| Facility | | $1,460.50 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.43 / $1,460.50 / $2,649.77
| Professional | | $1,241.43 | $1,460.50 | $2,649.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.25 / $1,265.95 / $1,848.76
| Professional | | $730.25 | $1,265.95 | $1,848.76 |