- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,542.24 / $1,542.24 / $1,542.24
| Facility | | $1,542.24 | $1,542.24 | $1,542.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,569.13
| Professional | | $1,494.41 | $1,494.41 | $1,569.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.86 / $1,445.86 / $1,445.86
| Professional | | $1,445.86 | $1,445.86 | $1,445.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $2,406.17
| Facility | | $1,494.41 | $1,494.41 | $2,406.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,903.26
| Professional | | $1,494.41 | $1,494.41 | $1,903.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.25 / $1,494.41 / $2,547.46
| Professional | | $1,270.25 | $1,494.41 | $2,547.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,576.60
| Professional | | $1,494.41 | $1,494.41 | $1,576.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,600.61 / $1,600.61 / $1,957.68
| Professional | | $1,600.61 | $1,600.61 | $1,957.68 |