- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.37 / $1,800.37 / $1,800.37
| Facility | | $1,800.37 | $1,800.37 | $1,800.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.37 / $2,050.17 / $2,050.17
| Professional | | $1,800.37 | $2,050.17 | $2,050.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,313.73 / $2,735.65 / $2,803.70
| Professional | | $2,313.73 | $2,735.65 | $2,803.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,837.63 / $2,866.00 / $3,603.78
| Professional | | $2,837.63 | $2,866.00 | $3,603.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,077.34 / $1,979.66 / $11,410.07
| Facility | | $1,077.34 | $1,979.66 | $11,410.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.84 / $1,636.31 / $2,001.25
| Professional | | $985.84 | $1,636.31 | $2,001.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.25 / $1,636.31 / $1,971.67
| Professional | | $727.25 | $1,636.31 | $1,971.67 |