- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,067.70 / $1,067.70 / $1,067.70
| Facility | | $1,067.70 | $1,067.70 | $1,067.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.70 / $1,432.05 / $12,753.10
| Professional | | $1,067.70 | $1,432.05 | $12,753.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,637.76 / $2,637.76 / $2,637.76
| Facility | | $2,637.76 | $2,637.76 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $2,637.76 / $2,716.89
| Professional | | $1,925.56 | $2,637.76 | $2,716.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,833.17 / $2,956.73 / $3,843.74
| Professional | | $1,833.17 | $2,956.73 | $3,843.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,546.48 / $3,955.25 / $3,955.25
| Facility | | $3,546.48 | $3,955.25 | $3,955.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,252.26 / $2,835.13 / $4,252.68
| Professional | | $2,252.26 | $2,835.13 | $4,252.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.29 / $1,653.86 / $2,366.73
| Professional | | $1,493.29 | $1,653.86 | $2,366.73 |