- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,775.02 / $1,775.02 / $1,775.02
| Facility | | $1,775.02 | $1,775.02 | $1,775.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.02 / $1,775.02 / $1,909.12
| Professional | | $1,775.02 | $1,775.02 | $1,909.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,587.14 / $2,895.89 / $5,429.79
| Facility | | $1,587.14 | $2,895.89 | $5,429.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.14 / $2,352.91 / $3,257.87
| Professional | | $990.14 | $2,352.91 | $3,257.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,861.13 / $2,861.13 / $4,144.01
| Facility | | $2,861.13 | $2,861.13 | $4,144.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.96 / $2,861.13 / $17,339.37
| Professional | | $2,431.96 | $2,861.13 | $17,339.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.91 / $2,243.67 / $3,009.85
| Professional | | $1,805.91 | $2,243.67 | $3,009.85 |