- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,935.75 / $1,935.75 / $1,935.75
| Facility | | $1,935.75 | $1,935.75 | $1,935.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,935.75 / $2,032.26 / $2,212.28
| Professional | | $1,935.75 | $2,032.26 | $2,212.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,375.33 / $2,375.33 / $2,375.33
| Facility | | $2,375.33 | $2,375.33 | $2,375.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.99 / $2,375.32 / $2,375.33
| Professional | | $1,733.99 | $2,375.32 | $2,375.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.80 / $2,709.68 / $16,837.56
| Facility | | $1,089.80 | $2,709.68 | $16,837.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.39 / $2,230.69 / $4,405.85
| Professional | | $1,125.39 | $2,230.69 | $4,405.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,834.85 / $3,834.85 / $3,834.85
| Facility | | $3,834.85 | $3,834.85 | $3,834.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.39 / $2,034.29 / $2,543.44
| Professional | | $1,125.39 | $2,034.29 | $2,543.44 |