- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.96 / $2,283.96 / $2,283.96
| Facility | | $2,283.96 | $2,283.96 | $2,283.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,283.96 / $2,918.41 / $2,918.41
| Professional | | $2,283.96 | $2,918.41 | $2,918.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,935.23 / $3,470.48 / $3,556.81
| Professional | | $2,935.23 | $3,470.48 | $3,556.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,039.50 / $4,079.90 / $5,130.17
| Professional | | $4,039.50 | $4,079.90 | $5,130.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,470.68 / $2,849.53 / $15,534.23
| Facility | | $1,470.68 | $2,849.53 | $15,534.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.65 / $2,179.51 / $2,538.82
| Professional | | $1,250.65 | $2,179.51 | $2,538.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.67 / $1,566.15 / $2,538.82
| Professional | | $968.67 | $1,566.15 | $2,538.82 |