- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,305.40 / $1,305.40 / $1,305.40
| Facility | | $1,305.40 | $1,305.40 | $1,305.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.14 / $1,127.14 / $1,305.40
| Professional | | $1,127.14 | $1,127.14 | $1,305.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,677.63 / $1,983.55 / $2,032.89
| Professional | | $1,677.63 | $1,983.55 | $2,032.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.00 / $1,575.60 / $1,981.20
| Professional | | $1,560.00 | $1,575.60 | $1,981.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $589.16 / $1,305.40 / $7,424.54
| Facility | | $589.16 | $1,305.40 | $7,424.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $559.46 / $1,007.02 / $1,429.61
| Professional | | $559.46 | $1,007.02 | $1,429.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.56 / $714.81 / $1,429.61
| Professional | | $447.56 | $714.81 | $1,429.61 |