- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,626.17 / $1,626.17 / $1,626.17
| Facility | | $1,626.17 | $1,626.17 | $1,626.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.17 / $1,858.48 / $1,876.04
| Professional | | $1,626.17 | $1,858.48 | $1,876.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.88 / $2,677.88 / $2,677.88
| Facility | | $2,677.88 | $2,677.88 | $2,677.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.85 / $2,677.88 / $2,677.88
| Professional | | $1,954.85 | $2,677.88 | $2,677.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,091.50 / $2,276.33 / $17,719.04
| Facility | | $1,091.50 | $2,276.33 | $17,719.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.15 / $2,234.19 / $3,836.77
| Professional | | $1,127.15 | $2,234.19 | $3,836.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.15 / $1,806.53 / $2,546.83
| Professional | | $1,127.15 | $1,806.53 | $2,546.83 |