- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,651.45 / $1,651.45 / $1,651.45
| Facility | | $1,651.45 | $1,651.45 | $1,651.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.10 / $1,617.53 / $1,651.45
| Professional | | $1,560.10 | $1,617.53 | $1,651.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.34 / $2,509.35 / $2,571.78
| Professional | | $2,122.34 | $2,509.35 | $2,571.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.88 / $2,725.86 / $3,427.57
| Professional | | $2,698.88 | $2,725.86 | $3,427.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $822.18 / $1,651.45 / $9,312.17
| Facility | | $822.18 | $1,651.45 | $9,312.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.44 / $981.24 / $1,808.59
| Professional | | $769.44 | $981.24 | $1,808.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.23 / $981.24 / $1,808.59
| Professional | | $589.23 | $981.24 | $1,808.59 |