- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,916.50 / $1,916.50 / $1,916.50
| Facility | | $1,916.50 | $1,916.50 | $1,916.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.50 / $2,156.67 / $2,156.67
| Professional | | $1,916.50 | $2,156.67 | $2,156.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,462.98 / $2,912.11 / $2,984.55
| Professional | | $2,462.98 | $2,912.11 | $2,984.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,985.00 / $3,014.85 / $3,790.95
| Professional | | $2,985.00 | $3,014.85 | $3,790.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,014.50 / $2,030.70 / $12,133.56
| Facility | | $1,014.50 | $2,030.70 | $12,133.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.37 / $1,712.48 / $2,130.34
| Professional | | $1,006.37 | $1,712.48 | $2,130.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.10 / $1,712.48 / $2,574.83
| Professional | | $761.10 | $1,712.48 | $2,574.83 |