- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,345.76 / $1,345.76 / $1,345.76
| Facility | | $1,345.76 | $1,345.76 | $1,345.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.76 / $1,559.24 / $2,214.56
| Professional | | $1,345.76 | $1,559.24 | $2,214.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,020.45 / $2,375.33 / $3,662.06
| Facility | | $2,020.45 | $2,375.33 | $3,662.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.99 / $1,733.99 / $3,206.62
| Professional | | $1,733.99 | $1,733.99 | $3,206.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,345.56 / $3,369.10 / $4,797.30
| Professional | | $3,345.56 | $3,369.10 | $4,797.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,576.23 / $3,662.06 / $3,662.06
| Professional | | $3,576.23 | $3,662.06 | $3,662.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,834.85 / $4,511.59 / $5,413.91
| Facility | | $3,834.85 | $4,511.59 | $5,413.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.24 / $1,957.50 / $3,662.06
| Professional | | $1,651.24 | $1,957.50 | $3,662.06 |