- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,442.17 / $1,442.17 / $1,442.17
| Facility | | $1,442.17 | $1,442.17 | $1,442.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,442.17 / $1,609.35 / $1,648.20
| Professional | | $1,442.17 | $1,609.35 | $1,648.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,283.76 / $2,283.76
| Facility | | $2,283.76 | $2,283.76 | $2,283.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.14 / $2,283.76 / $2,283.76
| Professional | | $1,667.14 | $2,283.76 | $2,283.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $863.01 / $2,018.77 / $14,087.74
| Facility | | $863.01 | $2,018.77 | $14,087.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.20 / $1,766.50 / $3,342.00
| Professional | | $891.20 | $1,766.50 | $3,342.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.20 / $1,515.59 / $2,013.70
| Professional | | $891.20 | $1,515.59 | $2,013.70 |