- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.63 / $836.63 / $836.63
| Facility | | $836.63 | $836.63 | $836.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.63 / $990.74 / $1,558.36
| Professional | | $836.63 | $990.74 | $1,558.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.83 / $1,271.83 / $2,276.61
| Facility | | $1,271.83 | $1,271.83 | $2,276.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.44 / $928.44 / $1,993.48
| Professional | | $928.44 | $928.44 | $1,993.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,079.86 / $2,094.48 / $2,982.36
| Professional | | $2,079.86 | $2,094.48 | $2,982.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,223.25 / $2,276.61 / $2,276.61
| Professional | | $2,223.25 | $2,276.61 | $2,276.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.53 / $1,216.94 / $2,090.05
| Professional | | $1,026.53 | $1,216.94 | $2,090.05 |