- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,602.45 / $1,602.45 / $1,602.45
| Facility | | $1,602.45 | $1,602.45 | $1,602.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.68 / $1,714.56 / $1,714.56
| Professional | | $1,454.68 | $1,714.56 | $1,714.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.37 / $2,434.90 / $2,495.46
| Professional | | $2,059.37 | $2,434.90 | $2,495.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,373.00 / $2,396.73 / $3,013.71
| Professional | | $2,373.00 | $2,396.73 | $3,013.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $800.82 / $1,602.45 / $8,608.62
| Facility | | $800.82 | $1,602.45 | $8,608.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.40 / $1,236.18 / $1,754.92
| Professional | | $794.40 | $1,236.18 | $1,754.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.41 / $1,236.18 / $1,960.56
| Professional | | $549.41 | $1,236.18 | $1,960.56 |